ORGANIZATION OF SERVICES FOR MENTAL
HEALTH
Mental Health Policy and Service Guidance Package
“Mental health care should be provided through general health
services and community settings.Large and centralized psychiatric institutions need to be replaced
by other more appropriate mental health services.”
ORGANIZATION OF SERVICES FOR MENTAL
HEALTH
Mental Health Policy and Service Guidance Package
© World Health Organization 2003. Reprinted 2007.
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WHO Library Cataloguing-in-Publication Data
Organization of services for mental health.
(Mental health policy and service guidance package)
1. Mental health services - organization and administration 2. Community mental health services -
organization and administration 3. Delivery of health care, Integrated 4. Health planning guidelines
I. World Health Organization II. Series
ISBN 92 4 154592 5 (NLM classification: WM 30)
Technical information concerning this publication can be obtained from:
Dr Michelle Funk
Department of Mental Health and Substance Abuse
World Health Organization
20 Avenue Appia
CH-1211, Geneva 27
Switzerland
Tel : +41 22 791 3855
Fax : +41 22 791 4160
E-mail : [email protected]
Suggested citation : Organization of services for mental health. Geneva, World Health Organization,
2003 (Mental Health Policy and Service Guidance Package).
ii
Acknowledgements
The Mental Health Policy and Service Guidance Package was produced under thedirection of Dr Michelle Funk, Coordinator, Mental Health Policy and ServiceDevelopment, and supervised by Dr Benedetto Saraceno, Director, Department ofMental Health and Substance Dependence, World Health Organization.
This module has been prepared by Dr Soumitra Pathare, Ruby Hall Clinic, India, Dr Michelle Funk and Ms Natalie Drew, World Health Organization, Switzerland andProfessor Alan Flisher, University of Cape Town, South Africa. Dr Silvia Kaaya, Dr GadKilonzo and Dr Jesse K. Mbwambo, Muhimbili Medical Centre, Tanzania and Dr IanLockhart, University of Cape Town, South Africa also drafted documents that were usedin its preparation.
Editorial and technical coordination group:
Dr Michelle Funk, World Health Organization, Headquarters (WHO/HQ), Ms NatalieDrew, (WHO/HQ), Dr JoAnne Epping-Jordan, (WHO/HQ), Professor Alan J. Flisher,University of Cape Town, Observatory, Republic of South Africa, Professor MelvynFreeman, Department of Health, Pretoria, South Africa, Dr Howard Goldman, NationalAssociation of State Mental Health Program Directors Research Institute and Universityof Maryland School of Medicine, USA, Dr Itzhak Levav, Mental Health Services, Ministryof Health, Jerusalem, Israel and Dr Benedetto Saraceno, (WHO/HQ).
Dr Crick Lund, University of Cape Town, Observatory, Republic of South Africa,finalized the technical editing of this module.
Technical assistance:
Dr Jose Bertolote, World Health Organization, Headquarters (WHO/HQ), Dr ThomasBornemann (WHO/HQ), Dr José Miguel Caldas de Almeida, WHO Regional Office forthe Americas (AMRO), Dr Vijay Chandra, WHO Regional Office for South-East Asia(SEARO), Dr Custodia Mandlhate, WHO Regional Office for Africa (AFRO), Dr ClaudioMiranda (AMRO), Dr Ahmed Mohit, WHO Regional Office for the Eastern Mediterranean,Dr Wolfgang Rutz, WHO Regional Office for Europe (EURO), Dr Erica Wheeler (WHO/HQ),Dr Derek Yach (WHO/HQ), and staff of the WHO Evidence and Information for PolicyCluster (WHO/HQ).
Administrative and secretarial support:
Ms Adeline Loo (WHO/HQ), Mrs Anne Yamada (WHO/HQ) and Mrs Razia Yaseen(WHO/HQ).
Layout and graphic design: 2S ) graphicdesignEditor: Walter Ryder
iii
WHO also gratefully thanks the following people for their expert opinion and technical input to this module:
Dr Adel Hamid Afana Director, Training and Education DepartmentGaza Community Mental Health Programme
Dr Bassam Al Ashhab Ministry of Health, Palestinian Authority, West BankMrs Ella Amir Ami Québec, CanadaDr Julio Arboleda-Florez Department of Psychiatry, Queen's University,
Kingston, Ontario, CanadaMs Jeannine Auger Ministry of Health and Social Services, Québec, CanadaDr Florence Baingana World Bank, Washington DC, USAMrs Louise Blanchette University of Montreal Certificate Programme in
Mental Health, Montreal, CanadaDr Susan Blyth University of Cape Town, Cape Town, South AfricaMs Nancy Breitenbach Inclusion International, Ferney-Voltaire, FranceDr Anh Thu Bui Ministry of Health, Koror, Republic of PalauDr Sylvia Caras People Who Organization, Santa Cruz,
California, USA Dr Claudina Cayetano Ministry of Health, Belmopan, BelizeDr Chueh Chang Taipei, TaiwanProfessor Yan Fang Chen Shandong Mental Health Centre, Jinan
People’s Republic of ChinaDr Chantharavdy Choulamany Mahosot General Hospital, Vientiane, Lao People’s
Democratic RepublicDr Ellen Corin Douglas Hospital Research Centre, Quebec, CanadaDr Jim Crowe President, World Fellowship for Schizophrenia and
Allied Disorders, Dunedin, New ZealandDr Araba Sefa Dedeh University of Ghana Medical School, Accra, GhanaDr Nimesh Desai Professor of Psychiatry and Medical
Superintendent, Institute of Human Behaviour and Allied Sciences, India
Dr M. Parameshvara Deva Department of Psychiatry, Perak College of Medicine, Ipoh, Perak, Malaysia
Professor Saida Douki President, Société Tunisienne de Psychiatrie,Tunis, Tunisia
Professor Ahmed Abou El-Azayem Past President, World Federation for Mental Health, Cairo, Egypt
Dr Abra Fransch WONCA, Harare, ZimbabweDr Gregory Fricchione Carter Center, Atlanta, USADr Michael Friedman Nathan S. Kline Institute for Psychiatric Research,
Orangeburg, NY, USAMrs Diane Froggatt Executive Director, World Fellowship for Schizophrenia
and Allied Disorders, Toronto, Ontario, CanadaMr Gary Furlong Metro Local Community Health Centre, Montreal, CanadaDr Vijay Ganju National Association of State Mental Health Program
Directors Research Institute, Alexandria, VA, USAMrs Reine Gobeil Douglas Hospital, Quebec, CanadaDr Nacanieli Goneyali Ministry of Health, Suva, FijiDr Gaston Harnois Douglas Hospital Research Centre,
WHO Collaborating Centre, Quebec, Canada Mr Gary Haugland Nathan S. Kline Institute for Psychiatric Research,
Orangeburg, NY, USADr Yanling He Consultant, Ministry of Health, Beijing,
People’s Republic of ChinaProfessor Helen Herrman Department of Psychiatry, University
of Melbourne, Australia
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Mrs Karen Hetherington WHO/PAHO Collaborating Centre, CanadaProfessor Frederick Hickling Section of Psychiatry, University of West Indies,
Kingston, JamaicaDr Kim Hopper Nathan S. Kline Institute for Psychiatric Research,
Orangeburg, NY, USADr Tae-Yeon Hwang Director, Department of Psychiatric Rehabilitation and
Community Psychiatry, Yongin City, Republic of KoreaDr A. Janca University of Western Australia, Perth, AustraliaDr Dale L. Johnson World Fellowship for Schizophrenia and Allied
Disorders, Taos, NM, USADr Kristine Jones Nathan S. Kline Institute for Psychiatric Research,
Orangeburg, NY, USADr David Musau Kiima Director, Department of Mental Health, Ministry of
Health, Nairobi, KenyaMr Todd Krieble Ministry of Health, Wellington, New ZealandMr John P. Kummer Equilibrium, Unteraegeri, SwitzerlandProfessor Lourdes Ladrido-Ignacio Department of Psychiatry and Behavioural Medicine,
College of Medicine and Philippine General Hospital,Manila, Philippines
Dr Pirkko Lahti Secretary-General/Chief Executive Officer, World Federation for Mental Health, and ExecutiveDirector, Finnish Association for Mental Health,Helsinki, Finland
Mr Eero Lahtinen, Ministry of Social Affairs and Health, Helsinki, FinlandDr Eugene M. Laska Nathan S. Kline Institute for Psychiatric Research,
Orangeburg, NY, USADr Eric Latimer Douglas Hospital Research Centre, Quebec, CanadaDr Ian Lockhart University of Cape Town, Observatory,
Republic of South AfricaDr Marcelino López Research and Evaluation, Andalusian Foundation
for Social Integration of the Mentally Ill, Seville, SpainMs Annabel Lyman Behavioural Health Division, Ministry of Health,
Koror, Republic of PalauDr Ma Hong Consultant, Ministry of Health, Beijing,
People’s Republic of ChinaDr George Mahy University of the West Indies, St Michael, BarbadosDr Joseph Mbatia Ministry of Health, Dar-es-Salaam, TanzaniaDr Céline Mercier Douglas Hospital Research Centre, Quebec, CanadaDr Leen Meulenbergs Belgian Inter-University Centre for Research
and Action, Health and Psychobiological and Psychosocial Factors, Brussels, Belgium
Dr Harry I. Minas Centre for International Mental Health and Transcultural Psychiatry, St. Vincent’s Hospital, Fitzroy, Victoria, Australia
Dr Alberto Minoletti Ministry of Health, Santiago de Chile, ChileDr P. Mogne Ministry of Health, MozambiqueDr Paul Morgan SANE, South Melbourne, Victoria, AustraliaDr Driss Moussaoui Université psychiatrique, Casablanca, MoroccoDr Matt Muijen The Sainsbury Centre for Mental Health,
London, United Kingdom Dr Carmine Munizza Centro Studi e Ricerca in Psichiatria, Turin, ItalyDr Shisram Narayan St Giles Hospital, Suva, FijiDr Sheila Ndyanabangi Ministry of Health, Kampala, UgandaDr Grayson Norquist National Institute of Mental Health, Bethesda, MD, USADr Frank Njenga Chairman of Kenya Psychiatrists’ Association,
Nairobi, Kenya
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Dr Angela Ofori-Atta Clinical Psychology Unit, University of Ghana MedicalSchool, Korle-Bu, Ghana
Professor Mehdi Paes Arrazi University Psychiatric Hospital, Sale, MoroccoDr Rampersad Parasram Ministry of Health, Port of Spain, Trinidad and TobagoDr Vikram Patel Sangath Centre, Goa, IndiaDr Dixianne Penney Nathan S. Kline Institute for Psychiatric Research,
Orangeburg, NY, USADr Yogan Pillay Equity Project, Pretoria, Republic of South AfricaDr M. Pohanka Ministry of Health, Czech RepublicDr Laura L. Post Mariana Psychiatric Services, Saipan, USADr Prema Ramachandran Planning Commission, New Delhi, IndiaDr Helmut Remschmidt Department of Child and Adolescent Psychiatry,
Marburg, GermanyProfessor Brian Robertson Department of Psychiatry, University of Cape Town,
Republic of South AfricaDr Julieta Rodriguez Rojas Integrar a la Adolescencia, Costa RicaDr Agnes E. Rupp Chief, Mental Health Economics Research Program,
NIMH/NIH, USADr Ayesh M. Sammour Ministry of Health, Palestinian Authority, Gaza Dr Aive Sarjas Department of Social Welfare, Tallinn, EstoniaDr Radha Shankar AASHA (Hope), Chennai, IndiaDr Carole Siegel Nathan S. Kline Institute for Psychiatric Research,
Orangeburg, NY, USAProfessor Michele Tansella Department of Medicine and Public Health,
University of Verona, ItalyMs Mrinali Thalgodapitiya Executive Director, NEST, Hendala, Watala,
Gampaha District, Sri LankaDr Graham Thornicroft Director, PRISM, The Maudsley Institute of Psychiatry,
London, United KingdomDr Giuseppe Tibaldi Centro Studi e Ricerca in Psichiatria, Turin, ItalyMs Clare Townsend Department of Psychiatry, University of Queensland,
Toowing Qld, AustraliaDr Gombodorjiin Tsetsegdary Ministry of Health and Social Welfare, MongoliaDr Bogdana Tudorache President, Romanian League for Mental Health,
Bucharest, RomaniaMs Judy Turner-Crowson Former Chair, World Association for Psychosocial
Rehabilitation, WAPR Advocacy Committee, Hamburg, Germany
Mrs Pascale Van den Heede Mental Health Europe, Brussels, BelgiumMs Marianna Várfalvi-Bognarne Ministry of Health, HungaryDr Uldis Veits Riga Municipal Health Commission, Riga, LatviaMr Luc Vigneault Association des Groupes de Défense des Droits
en Santé Mentale du Québec, CanadaDr Liwei Wang Consultant, Ministry of Health, Beijing,
People’s Republic of ChinaDr Xiangdong Wang Acting Regional Adviser for Mental Health, WHO Regional
Office for the Western Pacific, Manila, PhilippinesProfessor Harvey Whiteford Department of Psychiatry, University of Queensland,
Toowing Qld, AustraliaDr Ray G. Xerri Department of Health, Floriana, MaltaDr Xie Bin Consultant, Ministry of Health, Beijing,
People’s Republic of ChinaDr Xin Yu Consultant, Ministry of Health, Beijing,
People’s Republic of ChinaProfessor Shen Yucun Institute of Mental Health, Beijing Medical University,
People’s Republic of China
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Dr Taintor Zebulon President, WAPR, Department of Psychiatry, New York University Medical Center, New York, USA
WHO also wishes to acknowledge the generous financial support of the Governments ofAustralia, Finland, Italy, the Netherlands, New Zealand, and Norway, as well as the Eli Lillyand Company Foundation and the Johnson and Johnson Corporate Social Responsibility,Europe.
vii
viii
“Mental health care should be provided through general health
services and community settings.Large and centralized psychiatric institutions need to be replaced
by other more appropriate mental health services.”
Table of Contents
Preface xExecutive summary 2Aims and target audience 8
1. Introduction 9
2. Description and analysis of mental health services around the world 102.1 Mental health services integrated into the general health system 102.2 Community mental health services 142.3 Institutional services in mental hospitals 18
3. Current status of service organization around the world 23
4. Guidance for organizing services 314.1 Principles for the organization of services 314.2 Establishment of an optimal mix of services 334.3 Integration of mental health services into general health services 354.4 Creation of formal and informal community mental health services 384.5 Limitation of dedicated mental hospitals 42
5. Key issues in the organization of mental health services 465.1 Evidence-based care 465.2 Episodic care versus continuing care 485.3 Pathways to care 485.4 Geographical disparities 495.5 Service-led care versus needs-led care 505.6 Collaboration within and between sectors 51
6. Recommendations and conclusions 54
7. Scenarios for the organization of services in countries with various levels of resources 55
8. Barriers and solutions 57
9. Glossary 67
References 69
ix
Preface
This module is part of the WHO Mental Health Policy and Service guidance package,which provides practical information to assist countries to improve the mental healthof their populations.
What is the purpose of the guidance package?
The purpose of the guidance package is to assist policy-makers and planners to:
- develop policies and comprehensive strategies for improvingthe mental health of populations;
- use existing resources to achieve the greatest possible benefits;
- provide effective services to those in need;
- assist the reintegration of persons with mental disorders into all aspects of community life, thus improving their overall quality of life.
What is in the package?
The package consists of a series of interrelated user-friendly modules that are designedto address the wide variety of needs and priorities in policy development and serviceplanning. The topic of each module represents a core aspect of mental health. The startingpoint is the module entitled The Mental Health Context, which outlines the global contextof mental health and summarizes the content of all the modules. This module shouldgive readers an understanding of the global context of mental health, and should enablethem to select specific modules that will be useful to them in their own situations.Mental Health Policy, Plans and Programmes is a central module, providing detailedinformation about the process of developing policy and implementing it through plansand programmes. Following a reading of this module, countries may wish to focus onspecific aspects of mental health covered in other modules.
The guidance package includes the following modules:
> The Mental Health Context> Mental Health Policy, Plans and Programmes> Mental Health Financing> Mental Health Legislation and Human Rights> Advocacy for Mental Health> Organization of Services for Mental Health> Quality Improvement for Mental Health> Planning and Budgeting to Deliver Services for Mental Health
x
xi
still to be developed
MentalHealthContext
Legislation andhuman rights
Financing
Organizationof Services
Advocacy
Qualityimprovement
Workplacepolicies andprogrammes
Psychotropicmedicines
Informationsystems
Humanresources and
training
Child andadolescent
mental health
Researchand evaluation
Planning andbudgeting for
service delivery
Policy,plans and
programmes
Preface
The following modules are not yet available but will be included in the final guidancepackage:
> Improving Access and Use of Psychotropic Medicines> Mental Health Information Systems> Human Resources and Training for Mental Health> Child and Adolescent Mental Health> Research and Evaluation of Mental Health Policy and Services> Workplace Mental Health Policies and Programmes
Who is the guidance package for?
The modules will be of interest to:
- policy-makers and health planners;- government departments at federal, state/regional and local levels;- mental health professionals;- groups representing people with mental disorders;- representatives or associations of families and carers
of people with mental disorders;- advocacy organizations representing the interests of people with mental
disorders and their relatives and families;- nongovernmental organizations involved or interested in the provision
of mental health services.
How to use the modules
- They can be used individually or as a package. They are cross-referenced witheach other for ease of use. Countries may wish to go through each of the modulessystematically or may use a specific module when the emphasis is on a particular areaof mental health. For example, countries wishing to address mental health legislationmay find the module entitled Mental Health Legislation and Human Rights useful forthis purpose.
- They can be used as a training package for mental health policy-makers, plannersand others involved in organizing, delivering and funding mental health services. Theycan be used as educational materials in university or college courses. Professionalorganizations may choose to use the package as an aid to training for persons workingin mental health.
- They can be used as a framework for technical consultancy by a wide range ofinternational and national organizations that provide support to countries wishing toreform their mental health policy and/or services.
- They can be used as advocacy tools by consumer, family and advocacy organizations.The modules contain useful information for public education and for increasingawareness among politicians, opinion-makers, other health professionals and thegeneral public about mental disorders and mental health services.
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Format of the modules
Each module clearly outlines its aims and the target audience for which it is intended.The modules are presented in a step-by-step format so as to assist countries in usingand implementing the guidance provided. The guidance is not intended to be prescriptiveor to be interpreted in a rigid way: countries are encouraged to adapt the material inaccordance with their own needs and circumstances. Practical examples are giventhroughout.
There is extensive cross-referencing between the modules. Readers of one module mayneed to consult another (as indicated in the text) should they wish further guidance.
All the modules should be read in the light of WHO’s policy of providing most mentalhealth care through general health services and community settings. Mental health isnecessarily an intersectoral issue involving the education, employment, housing, socialservices and criminal justice sectors. It is important to engage in serious consultationwith consumer and family organizations in the development of policy and the deliveryof services.
Dr Michelle Funk Dr Benedetto Saraceno
xiii
ORGANIZATION OF SERVICES FOR MENTAL
HEALTH
Executive summary
Introduction
Mental health services are the means by which effective interventions for mental healthare delivered. The way these services are organized has an important bearing on theireffectiveness and ultimately on whether they meet the aims and objectives of a mentalhealth policy.
This module does not attempt to prescribe a single model for organizing services in aglobal context. The exact form of service organization and delivery ultimately dependson a country’s social, cultural, political and economic context. However, research findingsand experience in countries in different regions of the world point towards some of the keyingredients of successful service delivery models. This module indicates these ingredientsin order to give countries guidance on the organization of their mental health services.
Description and analysis of mental health services around the world
The various components of mental health services are categorized below. This is not arecommendation on the organization of services but an attempt to broadly map theservices that exist.
I) Mental health services integrated into the general health system can be as broadlygrouped as those in primary care and those in general hospitals.
Mental health services in primary care include treatment services and preventive andpromotional activities delivered by primary care professionals. Among them, for example,are services provided by general practitioners, nurses and other health staff based inprimary care clinics. The provision of mental health care through primary care requiressignificant investment in training primary care professionals to detect and treat mentaldisorders. Such training should address the specific needs of different groups of primarycare professionals such as doctors, nurses and community health workers.Furthermore, primary care staff should have the time to conduct mental health interventions.It may be necessary to increase the number of general health care staff if an additionalmental health care component is to be provided through primary care.
For most common and acute mental disorders these services may have clinical outcomesthat are as good as or better than those of more specialized mental health services.However, clinical outcomes are highly dependent on the quality of the servicesprovided, which in turn depends on the knowledge of primary care staff and theirskills in diagnosing and treating common mental disorders, as well as on the availabilityof drugs and other options for psychosocial treatment. Primary care services areeasily accessible and are generally better accepted than other forms of servicedelivery by persons with mental health disorders. This is mainly attributable to thereduced stigma associated with seeking help from such services. Both providers andusers generally find these services inexpensive in comparison with other mentalhealth services.
Mental health services in general hospitals include certain services offered in districtgeneral hospitals and academic or central hospitals that form part of the general healthsystem. Such services include psychiatric inpatient wards, psychiatric beds in generalwards and emergency departments, and outpatient clinics. There may also be somespecialist services, e.g. for children, adolescents and the elderly. These services areprovided by specialist mental health professionals such as psychiatrists, psychiatric
2
nurses, psychiatric social workers, psychologists, and physicians who have receivedspecial training in psychiatry. Clearly, such services require adequate numbers of trainedspecialist staff and adequate training facilities for them.
The clinical outcomes associated with these services are variable and depend ontheir quality and quantity. In many countries, the mental health services of generalhospitals can manage acute behavioural emergencies and episodic disorders whichrequire only outpatient treatment. However, their ability to help people with severemental disorders depends on the availability of comprehensive primary care servicesor community mental health services and on the continuity of care that these provide.Mental health services based in general hospitals are usually well accepted. Becausegeneral hospitals are usually located in large urban centres, however, there may beproblems of accessibility in countries lacking good transport systems. For serviceproviders, mental health services in general hospitals are likely to be more expensivethan services provided in primary care but less expensive than those provided inspecialized institutions. Service users also have to incur additional travel and timecosts that can create additional access barriers in some countries.
II) Community mental health services can be categorized as formal and informal.
Formal community mental health services include community-based rehabilitationservices, hospital diversion programmes, mobile crisis teams, therapeutic and residentialsupervised services, home help and support services, and community-based servicesfor special populations such as trauma victims, children, adolescents and the elderly.Community mental health services are not based in hospital settings but need closeworking links with general hospitals and mental hospitals. They work best if closelylinked with primary care services and informal care providers working in the community.These services require some staff with a high level of skills and training, although manyfunctions can be delivered by general health workers with some training in mentalhealth. In many developing countries, highly skilled personnel of this kind are notreadily available and this restricts the availability of such services to a small minority ofpeople.
Well-resourced and well-funded community mental health services provide an opportunityfor many persons with severe mental disorders to continue living in the community andthus promote community integration. High levels of satisfaction with community mentalhealth services are associated with their accessibility, a reduced level of stigma associatedwith help-seeking for mental disorders and a reduced likelihood of violations of humanrights. Community mental health services of good quality, providing a wide range ofservices to meet diverse clinical needs, are demanding in terms of cost and personnel.Reductions in costs relative to those of mental hospitals are likely to take many yearsto materialize.
Informal community mental health services may be provided by local community membersother than general health professionals or dedicated mental health professionals andparaprofessionals. Informal providers are unlikely to form the core of mental healthservice provision and countries would be ill-advised to depend solely on their services,which, however, are a useful complement to formal mental health services and canbe important in improving the outcomes of persons with mental disorders. Suchservice providers usually have high acceptability and there are few access barriers asthe providers are nearly always based in the communities they serve. Although theservices are classed as informal, not all of them are totally free. In many countries, forinstance, traditional healers charge for their services and could therefore be consideredas providing private formal health care services. Moreover, there are concerns aboutviolations of human rights in relation to the treatment methods employed by sometraditional healers and faith healers.
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III) Institutional mental health services include specialist institutional services and mentalhospitals. A key feature of these services is the independent stand-alone service style,although they may have some links with the rest of the health care system.
Specialist institutional mental health services are provided by certain outpatient clinicsand by certain public or private hospital-based facilities that offer various services ininpatient wards. Among the services are those provided by acute and high securityunits, units for children and elderly people, and forensic psychiatry units. These servicesare not merely those of modernized mental hospitals: they meet very specific needs thatrequire institutional settings and a large complement of specialist staff who have beenproperly trained. The scarcity of such staff presents a serious problem in developingcountries. Specialist services are usually tertiary referral centres and patients who aredifficult to treat make up a large proportion of their case-loads. If well funded and wellresourced they provide care of high quality and produce outcomes that are goodenough to justify their continuation. Nearly all specialist services have problems ofaccess, both in developing countries and in the developed world. These problems maybe associated with a lack of availability, with location in urban centres that haveinadequate transport links, and with stigma attached to seeking help from such services.Specialist services are costly to set up and maintain, mainly because of the high levelof investment in infrastructure and staff. In many developing countries the cost of specialistunits is not necessarily high because staff costs are lower than in developed countriesand, in many cases, investments are at a low level and units function in substandardconditions.
Dedicated mental hospitals mainly provide long-stay custodial services. In many partsof the world they are either the only mental health services or remain a substantialcomponent of such services. In many countries they consume most of the available humanand financial resources for mental health. This is a serious barrier to the development ofalternative community-based mental health services. Mental hospitals are frequentlyassociated with poor outcomes attributable to a combination of factors such as poorclinical care, violations of human rights, the nature of institutionalized care and a lackof rehabilitative activities. They therefore represent the least desirable use of scarcefinancial resources available for mental health services. This is particularly true in thosedeveloping countries where mental hospitals provide the only mental health services.Stigma associated with mental hospitals also reduces their acceptability and accessibility.
Current status of service organization around the world
Very few countries have an optimal mix of services. Some developing countries mademental health services more widely available by integrating them into primary care services.Other countries have also made mental health services available at general hospitals. Insome countries there are good examples of intersectoral collaboration between non-governmental organizations, academic institutions, public sector health services, informalmental health services and users, leading to the development of community-basedservices. Even within countries there are usually significant disparities between differentregions, and both types of service are only available to small proportions of populations,usually in urban areas or selected rural areas.
In developed countries the process of deinstitutionalization during the last three decadeshas led to reductions in the populations of mental hospitals and to the closure of manyof these institutions. However, this has not been accompanied by sufficient provisionof community-based services, which are often inadequate and unevenly distributed.There is insufficient emphasis on developing mental health services in primary care. Forexample, although depression is a common problem in primary care settings, it is still notidentified or is undertreated by primary care practitioners in many developed countries.
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Two main conclusions can be drawn from global experience. Firstly, mental healthservices pose challenges in both developing countries and developed countries.However, the nature of the challenges differs. In many developing countries there isgross underprovision of resources, personnel and services, and these matters needimmediate attention. In developed countries some of the problems relate to insufficientcommunity reprovision, the need to promote the detection and treatment of mentaldisorders in primary care settings, and the competing demands of general psychiatricservices and specialist services. Secondly, more expensive specialist services are notthe answer to these problems. Even within the resource constraints of health servicesin most countries, significant improvements in delivery are possible by redirectingresources towards services that are less expensive, have reasonably good oucomesand benefit increased proportions of populations.
Guidance for organizing services
The recommendations in this module are intended to form an integrated system ofservice delivery and should not be interpreted in isolation from each other. None of therecommendations can be expected to succeed on its own in improving the care of personswith mental disorders. Service organization should be based on principles of accessibility,coordinated care, continuity of care, effectiveness, equity and respect for human rights.
Service planners have to determine the exact mix of different types of mental healthservices and the level of provision of particular service delivery channels. The absoluterequirement for various services differs greatly between countries but the relative needsof different services are broadly similar in many countries. It is clear that the mostnumerous services should be informal community mental health services and community-based mental health services provided by primary care staff, followed by psychiatricservices based in general hospitals, formal community mental health services and, lastly,specialist mental health services. There is little justification for including the kind of servicesprovided by mental hospitals. There will always be a need for long-stay facilities for anextremely small proportion of patients, even if the provision of community-based servicesis of a high order. However, most of these patients can be accommodated in smallunits located in the community, approximating community living as far as possible, oralternatively, in small long-stay wards in hospitals that also provide other specialistservices. Custodial care in large institutions, as provided by mental hospitals, is notjustified by its cost, its effectiveness or the quality of care provided.
The integration of mental health services into general health services helps to reducethe stigma associated with seeking help from stand-alone mental health services. Italso helps to overcome the acute shortage of mental health professionals and toencourage the early identification of mental disorders in people presenting withpsychosomatic symptoms in general health services. Other potential benefits includepossibilities for providing care in the community and opportunities for communityinvolvement in care. The integration of mental health services into general health servicesis the most viable strategy for extending mental health services to underservedpopulations.
Integration can be pursued at the clinical, managerial, administrative and financiallevels. Potentially, however, full integration has both benefits and drawbacks, andcountries have to take their own circumstances into account when choosing betweenfull and partial integration. There should be good integration at least at the clinical level.This involves integration into primary care settings, the integration of mental healthservices into general hospitals, the development of links between primary care andsecondary services and the integration of mental health into other established healthand social programmes.
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Integration into primary care requires that primary care staff be trained to assumeresponsibilities for the provision of mental health services and the promotion of mentalhealth. Many countries also need to invest in additional primary care staff so that theyhave sufficient time to deliver mental health interventions. Among other issues that needto be addressed are the provision of adequate infrastructures, the availability of equipmentand, most importantly, the availability of psychotropic medication.
Integration into general hospitals requires the provision of facilities such as outpatientdepartments and psychiatric wards in general hospitals as well as the availability ofmental health professionals, e.g. psychiatrists, psychologists, psychiatric nurses andsocial workers.
The need for good linkages between primary health care and secondary mental healthfacilities cannot be overstressed. A clear referral and linkage system should be put inplace and operated in consultation with service providers at the district and regional levels.
In developing countries the integration of mental health services into established physicalhealth and social programmes provides a feasible and affordable way of implementingmental health programmes. Thus maternal depression can be tackled as within awider reproductive health programme, women’s mental health can be considered inprogrammes concerned with domestic violence, and mental health needs can be dealtwith in HIV/AIDS programmes.
It is necessary for countries to build formal and informal mental health services. Thedevelopment of community services is essential if dependence on institutional servicesis to be reduced. In developing countries the lack of financial and human resourcesrequires these services to be developed in a phased manner that varies with localpriorities for specific community services. Developing countries also have to utilizeexisting networks of nongovernmental organizations for providing some of thesecommunity-based services, e.g. clubhouses, support groups, employment or rehabilitationworkshops, sheltered workshops, supervised work placements, and staffed residentialaccommodation.
Deinstitutionalization is an essential part of the reform of mental health services. Thismeans more than discharging people from long-stay hospitals. It requires significantchanges involving the use of community-based alternatives rather than institutions forthe delivery of services. The provision of services in the community should go hand-in-hand with reducing the populations of mental hospitals. Deinstitutionalization can proceedin stages once community-based alternatives are in place. Achieving it requires strongcommitment among planners, managers and clinicians.
Key issues in the organization of mental health services
The above recommendations for organizing mental health services should take intoaccount the evidence base for mental health interventions, the unique needs of thosewith mental disorders, the way communities and patients access services and otherimportant structural issues such as the need for intersectoral collaboration.
There is evidence that community-based treatment is associated with substantiallybetter outcomes than inpatient treatment and care, and that shorter stays in hospitalare as effective as longer stays. Some conditions, e.g. depression, can be effectivelytreated by primary care personnel using a combination of medications and counsellingor psychotherapy. With regard to schizophrenia, regular medication and familyintervention can substantially reduce the relapse rate and thus improve patients’quality of life.
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Health care systems should orient themselves towards the needs of the many personswith severe and long-term mental disorders. These people are ill-served by a throughputmodel of care that emphasizes the importance of vigorous treatment of acute episodesin the expectation that most patients will make a reasonably complete recovery withoutthe need for continuing care until the next acute episode. A continuing care approachis more appropriate for people with severe and long-term mental disorders. It emphasizesthe need to address the totality of patients’ needs, including social, occupational andpsychological requirements.
The pathways to care, i.e. the routes whereby people with mental disorders accessthe providers of mental health services, differ between developed and developingcountries because of different levels of health system development. These pathwaysmay occasionally hinder access to mental health services, resulting in delays in help-seeking and a higher likelihood of poor long-term outcomes. Planners should designservice delivery so as to overcome the barriers, improve access and thus reduce theduration and severity of disability caused by mental disorders.
Planners should aim to eliminate disparities in mental health services between rural andurban settings. Examples are given in the present module of programmes that attemptto diminish such disparities.
Services are usually organized from a managerial perspective and users are forcedto adjust to the particular structure of the service they wish to access. This service-ledapproach is characteristic of many mental health services. Unlike the needs-led approach,it results in significant barriers to access, especially for people with severe mentaldisorders whose needs go beyond purely medical and therapeutic interventions. Thereis a move towards models of service provision that are needs-led, e.g. case management,assertive treatment programmes and psychiatric rehabilitation villages in rural areas.These models are an acknowledgment that the needs of patients should be placed firstand that services should adapt their organization to meet these needs.
The complex needs of many persons with mental disorders cannot be met by the healthsector alone. Intersectoral collaboration is therefore essential. Collaboration is neededboth within the health sector (intrasectoral collaboration) and outside the health sector(intersectoral collaboration).
Acknowledging the need for collaborative efforts is the first step towards enhancingcollaboration between and within sectors. Mental health agencies and personsinvolved in the planning and delivery of mental health services should take a lead inexplaining what is required to other people, especially people outside the health sector.Collaboration can be improved by involving other sectors in policy formulation, delegatingthe responsibility for certain activities to agencies from other sectors, establishinginformation networks with agencies from other sectors and among other measures, byestablishing a national advisory committee with the participation of relevant agenciesfrom sectors outside mental health.
The last two sections in this module present recommendations for immediate action,discuss barriers to the implementation of services and outline possible ways ofovercoming them.
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8
Aims and target audience
This module aims to:
- present a description and analysis of mental health services around the world, examining different services and their organization and activities;
- review the current status of service organization around the world; - make recommendations for organizing services; - discuss crucial issues in the organization of services; - discuss barriers to the organization of services
and suggest solutions.
The module will be of interest to:
- policy-makers and health planners; - government departments at the national, regional and local levels;- mental health professionals; - people with mental disorders and their representative organizations; - representatives or associations of families and carers
of persons with mental disorders; - advocacy organizations representing the interests of persons
with mental disorders and their relatives and families; - nongovernmental organizations involved or interested
in the provision of mental health services.
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1. Introduction
Services are the means by which effective interventions for mental health are delivered.The organization of services is therefore a critical aspect of mental health care. Atbest, the way in which mental health services are organized enhances the aims andobjectives of national mental health policy. Poorly organized services fail to meet theexpectations and needs of people with mental disorders and impose costs withoutcommensurate benefits.
This module does not attempt to prescribe a single model for the organization of servicesin a global context. The exact form of service organization and delivery depends on thesocial, cultural, political and economic context. The availability of financial and humanresources differs between countries. Cultural aspirations and values also differ, evenbetween different regions in particular countries. Consequently, it is highly unlikely thatany given model of service delivery can fully meet the needs of all persons with mentaldisorders in all countries.
However, practical experience in countries and research findings in different regionsof the world point towards certain key ingredients of successful models of servicedelivery. The present module sets out these key ingredients in order to provide guidanceto countries on the organization of their mental health services. It is aimed at all countriesinterested in restructuring their mental health services.
The organization of services is a critical aspect of mental health care.
The exact form of service organization and deliverydepends on the local context.
In spite of global diversity, certain key ingredients of successful service organization can be identified.
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2. Description and analysis
of mental health services around the world
A schematic representation of different components of mental health services foundacross the world is given in Figure 1. The framework aims to broadly map the variety ofservices in different countries with varying health systems and varying levels of careprovision. It is not a recommendation on organization but an attempt to describe varioustypes of services.
Figure 1: Components of mental health services
Each of the categories is described in detail below. The descriptions are followed bybrief discussions of the implications, potential benefits and disadvantages of eachcategory for service providers and people with mental disorders.
2.1 Mental health services integrated into the general health system
Two service categories can be identified within the broad category of integrated mentalhealth services:
- mental health services in primary care;- mental health services in general hospitals.
Mental healthservices
in primaryhealth care
Mental healthservices in primary
health care
The health system
Community-basedmental health
services
Mental hospitalinstitutional
services
Mental healthservices
in generalhospital
Formalcommunity
mental healthservices
Informalcommunity
mental healthservices
Specialistinstitutional
mental healthservices
Dedicatedmental hospitals
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2.1.1 Mental health services in primary care
This category includes treatment and preventive and promotional interventions conductedby primary care professionals. Examples are given below. Of course, all of theseinterventions do not necessarily take place in every country. Furthermore, specialiststaff rather than primary care professionals may perform some of the functionsdescribed in the examples below. The way in which countries organize these activitiesmay vary, depending on the context, e.g. the organization of services and the availabilityof specialist staff.
Following are some examples of primary care providers:
a) general practitioners, nurses and other health care staff based in primary care clinics providing diagnostic, treatment and referral services for mental disorders;
b) general practitioners, nurses and other workers making home visits for the management of mental disorders;
c) non-medical primary care staff providing basic health services in rural areas; d) non-medical primary care staff involved in health promotion and prevention
activities, e.g. running clinics for mental health education and screening for mental disorders in schools;
e) primary care workers and aid workers providing information, education, guidance and treatment interventions for trauma victims in the context of natural disasters and acts of violence.
Potential benefits and disadvantages of primary care services
I) Human resources: Providing mental health care through primary care requires significantinvestment in training primary care professionals to detect and treat mental disorders.Such training should address the specific practical training needs of different groupsof primary care professionals, e.g. doctors, nurses and community health workers.Preferably, ongoing training programmes should be provided rather than single workshopsthat do not provide subsequent support for reinforcing new skills. In many countries thishas not happened and primary health care professionals are not well equipped to workwith people who have mental disorders and who therefore receive suboptimal care.Primary care staff are generally well qualified to provide help for people with physicaldisorders but many are uncomfortable about dealing with mental disorders. Indeed,many primary care staff may question their role in managing mental disorders. Trainingprogrammes should include coverage of these issues.
A related issue is that one of the main reasons for the reluctance of some primary carestaff to provide mental health services is that they do not have sufficient time to conductthe required interventions. It may be necessary to increase the number of primary carestaff if they are to add mental health care to their practice. However, it has been arguedthat primary care workers can save time by addressing the mental health needs of peoplewho present to services with physical complaints that have a psychological etiology(Goldberg & Lecrubier, 1995; Üstün and Sartorius, 1995).
II) Clinical outcomes: Conventional logic suggests that basic primary services yield lessfavourable outcomes than more specialized services but this is not necessarily true. Formost common and acute mental disorders these services may give equally good orsuperior clinical outcomes (see Section 7.1). There are three possible explanations forthis. First, users are more likely to seek early help for mental disorders because ofreduced costs and high acceptability. Second, there is an opportunity for the earlydetection of mental disorders when users seek help for physical problems. Third, primarycare workers may have a greater insight than more specialized workers into the cultural
Primary care services may include mental health care and promotional and preventive activities conducted by primary care professionals.
Significant investment is needed in the training of primary care professionals.
Increased numbers of primary care professionals may be needed to deliver mental health interventions
For a number of mental disorders, good clinical outcomes can be obtained in primary care settings .
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and interpersonal contexts of service users. Users may thus feel more understood atthe primary care level. Moreover, service providers may recognize strengths in users’cultural and interpersonal contexts which can be exploited for therapeutic purposes.However, clinical outcomes are highly dependent on the quality of the services provided,as affected by the knowledge of primary care staff, their skills in diagnosing andtreating common mental disorders, the time available, and access to psychotropicmedication and psychosocial treatment.
III) Acceptability: Primary health care services are generally relatively acceptable topeople with mental disorders. Less stigma is associated with seeking help from primarycare services, partly because they provide both physical and mental health care.Furthermore, primary care services are less likely to result in violations of the humanrights of persons with mental disorders.
IV) Access: Access to primary care services is good as they are geographically closeto users and are usually open at times determined with reference to local work patterns.Access is also favoured by comparatively low indirect costs. These increase theprobability of poor people using such services.
V) Financial costs: These services tend to be less expensive than others because oflower human resource costs, reduced costs of physical facilities as a result of the jointuse of facilities for general health care, less need for specialized equipment and less useof inpatient facilities. There are lower indirect costs for people with mental disordersbecause these services tend to be geographically closer to the patients so that lesstravelling and time are required in order to benefit from them.
2.1.2 Mental health services in general hospitals
A number of mental health services may be offered in secondary district or tertiaryacademic/central hospitals that form part of the general health system. Common facilitiesfor adults include psychiatric inpatient wards, psychiatric beds in general wards,psychiatric emergency departments and outpatient clinics. Services for children andadolescents are found in general, academic or children’s hospitals. These may includepsychiatric wards for children and adolescents and child/adolescent outpatient clinics.Services for the elderly are found in general and academic hospitals and includepsychogeriatric wards, psychiatric beds in other wards, and outpatient clinics. Theseservices are provided by specialist mental health professionals such as psychiatrists,psychiatric nurses, psychiatric social workers, psychologists, and physicians with specialtraining in psychiatry. Examples of mental health services offered by general hospitalsare given in Box 1.
Primary care services are well accepted.
Primary care services are generally more accessible.
Mental health interventionsdelivered through primary care may be less expensive than other forms of service delivery.
Certain mental health services may be provided in district general hospitals and in tertiary and academic hospitals.
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Box 1. Mental health services offered by general hospitals
> Acute inpatient care > Crisis stabilization care> Partial (day/night) hospital programmes> Consultation/liaison services for general medical patients > Intensive/planned outpatient programmes> Respite care> Expert consultation/support/training for primary care services> Multidisciplinary psychiatric teams linked with other local and provincial sectors
(schools, employers, correctional services, welfare) and nongovernmental organizations in intersectoral prevention and promotion initiatives
> Specialized units/wards for persons with specific mental disorders and for related rehabilitation programmes
Potential benefits and disadvantages of mental health services in general hospitals
I) Human resources: These services require adequate numbers of specialist mentalhealth professionals such as psychiatrists, psychologists, psychiatric social workersand psychiatric nurses. Consequently, investment is necessary in facilities wheresuch staff can be trained. There are a number of advantages in having mental healthprofessionals who are based in general hospitals. They can participate in undergraduateand postgraduate medical teaching and training, thus sensitizing physicians to mentaldisorders. Psychiatric departments in general hospitals can act as centres for postgraduatetraining in psychiatry and can provide opportunities for training other mental healthprofessionals, e.g. psychologists, nurses and social workers.
II) Clinical outcomes: These vary, depending on the quality and quantity of the servicesprovided. In many developing countries the only mental health services in generalhospitals are outpatient departments, short-stay inpatient wards for the acutely ill, andconsultation/liaison services provided by psychiatric departments to other medicaldepartments. In such circumstances, mental health services can manage acutebehavioural emergencies reasonably well but have little to offer persons with severemental disorders who may enter an admission-discharge-readmission cycle (the revolvingdoor syndrome) unless comprehensive primary care services or community servicesare also available. The absence of psychotherapy and psychosocial therapies alsolimits the ability of such services to improve outcomes for people suffering fromnon-psychotic illnesses.
III) Acceptability: General hospital-based services are usually acceptable to peoplewith mental disorders. There is less stigma associated with obtaining help from suchservices than from dedicated mental hospitals. The open nature of general hospitalsmakes it less likely that violations of human rights will occur than in closed institutions.
IV) Access: General hospital services are usually located in district headquarters whiletertiary/academic centres are usually located in big cities. Particularly in developingcountries, access to services based in general hospitals can be hindered by the financialcosts. The lack of reliable and cheap public transport services in many countries mayexclude many people who do not live in the urban areas where such hospitals are sited.However, mental health services based in general hospitals have the advantages ofrelatively easy access to specialist investigations and treatment as well as medicaltreatment for comorbid physical illnesses.
Specialist human resourcesare needed for mental healthin general hospitals.
Clinical outcomes depend on the quality and quantity of service provision.
These services are generally acceptable to people with mental disorders.
Mental health services based in general hospitals have some access problems but also enjoy certain advantages.
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V) Financial costs: For service providers, mental health services in general hospitals arelikely to be more costly than services provided in primary care settings. This is becauseof infrastructural costs, the costs of providing for inpatient care, and higher staff costsattributable to the use of specialist personnel such as psychiatrists and other mentalhealth professionals. However, mental health services in general hospitals may be lessexpensive than services provided in specialized institutions. For users, services basedin general hospitals tend to cost more than those based in primary care settingsbecause of the additional costs of travelling and the loss of employment, i.e. indirectcosts. In rural areas, general hospital-based services save transport costs for serviceproviders by transferring them to users. This transfer of financial burden can createaccess barriers in developing countries, in many of which the indirect costs aredisproportionately high in comparison with people’s ability to spend directly onmental health services.
2.2 Community mental health services
Community mental health services can be subdivided into those that are formal andthose that are informal.
2.2.1 Formal community mental health services
Formal community mental health services include a wide array of settings and differentlevels of care provided by mental health professionals and paraprofessionals, i.e. peoplewho work alongside professionals in an auxiliary capacity. These services includecommunity-based rehabilitation services, hospital diversion programmes, mobile crisisteams, therapeutic and residential supervised services, home help and support services,and community-based services for special populations such as trauma victims, children,adolescents and the elderly. Community mental health services are not based inhospital settings but need close working links with general hospitals and mental hospitals.These links may include, for example, a two-way referral system whereby generalhospitals and mental hospitals accept patients for short-term management and referpatients who are to be discharged into the community. Community mental healthservices work best when they are closely linked with primary care services and informalcare providers working in the community. Box 2 gives examples of formal communitymental health services.
These services are more expen-sive to provide than those inprimary care settings but maybe less expensive than servicesprovided in specialist institu-tions.
Community mental health services need good links with primary and secondaryhealth care and also withproviders of informal community mental health services.
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Box 2. Examples of formal community mental health services
Rehabilitation services> Community mental health centres/outpatient clinics > Clubhouses> Day care centres> Drop-in centres> Support groups> Employment/rehabilitation workshops> Sheltered workshops> Supervised work placements> Cooperative work schemes> Supported employment programmes
Hospital diversion programmes and mobile crisis teams> Mobile services for crisis assessment and treatment
(including evenings and weekends) operating from community mental health centres or outpatient clinics
Crisis services> Ordinary houses in neighbourhood settings with 24-hour care
given by mental health professionals> Support staff with mental health training and knowledge who can stay in a patient’s
own home overnight to provide support and supervision during a period of crisis> Crisis centres
Therapeutic and supervised residential services> Apartment buildings for ex-patients (unsupervised)> Scattered apartments each occupied by two or three residents (unsupervised)> Group homes (staffed and unstaffed)> Hostels > Halfway houses> Psychiatric agricultural rehabilitation villages > Ordinary housing
Home health services> Assessment, treatment and management coordinated
by a home care clinician from a community mental health centre> Case management and assertive community treatment > Domiciliary support centres
Others> Clinical services in educational, employment and correctional settings> Telephone hotline services> Trauma relief programmes in refugee camps or community settings
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Potential benefits and disadvantages of community mental health services
I) Human resources: Formal community mental health services require at least somestaff with a high level of skills and training. However, many functions can be deliveredby health workers with some training in mental health. The labour-intensive nature ofcommunity mental health services means that greater numbers of staff are needed thanin other mental health services in order to maximize reach.
II) Clinical outcomes: These depend on the quality of service provision. Well-resourcedand well-funded community mental health services give many people who have severemental disorders an opportunity to continue living in the community, thus promotingcommunity integration (see Section 7.1). Many community mental health services, e.g.day centres, sheltered workshops and supported housing, play a crucial role in givingsocial care to people with mental disorders. This can have a significantly positive impacton clinical outcomes and the quality of life.
III) Acceptability: High levels of satisfaction with community mental health services areassociated with their accessibility, reduced stigma associated with help-seeking formental disorders and a reduced likelihood of human rights violations.
IV) Access: Community mental health services are highly accessible to users, especiallythose with severe mental disorders requiring continuing input from mental healthservices. These services are less stigmatizing than segregated mental hospitals, andthis further improves their accessibility. The main barriers to access arise from thepaucity of such services, which may be attributable to the high costs of setting up andrunning them and to shortages of trained personnel. These barriers are especiallynoticeable in developing countries, where community mental health services are usuallyonly available to a small minority of people. Rural populations and minorities indeveloped countries face similar barriers to access because of the unavailability of suchservices.
V) Financial costs: In many countries, deinstitutionalization followed by communityreprovision has been driven by the expectation of lower costs for service providers,especially public health providers. However, experience during the past decade suggeststhat the cost savings are minimal, particularly in the short term. Community serviceproviders have to incur additional expenditure on travel and transport for staff, especiallyin rural areas. Additionally, fewer users can be assisted because of the time required fortravelling. Community mental health services of good quality which provide a widerange of services meeting diverse clinical needs are cost-intensive and personnel-intensive. Any cost savings are likely to take many years to materialize. Savings resultfrom reduced use of inpatient beds, which are an expensive resource in most developedcountries and many developing countries. There are cost savings for people with mentaldisorders through reduced travel and reduced indirect costs as services go to the userrather than the other way round.
2.2.2 Informal community mental health services
In addition to professionals and paraprofessionals in the fields of general health or mentalhealth, local community members may provide a variety of mental health services.Although these people may have received little or no formal training in mental healthskills, they can provide much of the required care, especially in settings where peoplewith mental disorders live at home with their families. Informal mental health providersvary according to the different mental health resource scenarios and sociopoliticalsituations of countries and regions. Box 3 contains examples of providers of informalcommunity mental health services.
Community mental health services require specialist staff in adequate numbers. This may be difficult to achieve in developing countries.
Well-resourced services have reasonably good outcomes.
These services generally enjoy high levels of user satisfaction.
Community mental health services are highly accessible to users.
Community services are not inexpensive and do not necessarily result in overall cost savings for service providers.
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Providers of informal community mental health services are unlikely to form the core ofmental health service provision. Countries would be ill-advised to depend solely onthese services. However, they are a useful complement to formal mental health services.
Traditional healers do not easily fit into specific service categories in this section.Traditional healers may be faith healers, spiritual healers, religious healers or practitionersof indigenous or alternative systems of medicine. In some countries they may be partof the informal health sector. However, in many others they charge for their servicesand should therefore be considered as part of the privately provided formal health careservices. In many countries they are the first point of contact for a majority of peoplewith mental disorders and sometimes they give the only available services. They alsohave high acceptability and in general are readily accessible because they are usuallymembers of the local communities that they serve. Notwithstanding the important roleplayed by traditional healers in many societies in providing care to persons with mentaldisorders, it should be noted that some traditional healing practices have been associatedwith human rights violations. In particular there are concerns about violations of the rightsof vulnerable groups, e.g. children, women and the elderly.
Box 3. Examples of providers of informal community mental health services
> Traditional healers> Village or community workers> Family members> Self-help and user groups> Advocacy services> Lay volunteers providing parental and youth education
on mental health issues and screening for mental disorders (including suicidal tendencies) in clinics and schools
> Religious leaders providing health information on trauma reactions in complex emergencies
> Day care services provided by relatives, neighbours or retired members of local communities
> Humanitarian aid workers in complex emergencies.
Informal providers cannot be solely relied on to provide mental health services.
Traditional healers are a heterogeneous group.
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Potential benefits and disadvantages of informal community mental health services
I) Human resources: In general these are readily obtainable in most communities,especially in rural and isolated communities where formal health services are not easilyavailable.
II) Clinical outcomes: These services can play an important supportive role in improvingoutcomes for persons with mental disorders. They are important for maintaining integrationin communities and providing support networks that minimize the risk of relapse. Inmany developing countries they are the main source of mental health provision and aremost likely to be used by people with acute, brief and psychosocial stress-drivenmental disorders.
III) Acceptability: This tends to be high as communities perceive them as being moreresponsive to their expressed needs. These services are usually consonant withcommunity perceptions and explanatory models of mental disorders and their treatment.There are, however, some concerns about human rights violations, especially regardingthe use of traumatic treatment methods and the risk of violations of the rights ofvulnerable populations, e.g. children, women and the elderly. Interventions are notsubject to quality control measures such as may apply to public providers.
IV) Access: There are few access barriers because these services are nearly alwaysbased in the community and enjoy a high degree of acceptability, thus reducing thelikelihood of stigma associated with their use.
V) Financial costs: Informal mental health services generally enjoy a significant costadvantage in comparison with nearly all formal mental health services (see discussionon traditional healers above). However, not all these services are necessarily free andusers may have to bear some costs.
2.3 Institutional services in mental hospitals
The key feature of these services is their independent stand-alone style, although theymay have some links with the rest of the health care system. They can be subdividedinto specialist institutional mental health services and dedicated mental hospitals.
2.3.1 Specialist institutional mental health services
These are usually specialist public or private hospital-based facilities offering variousservices in inpatient wards and in specialist outpatient clinic settings. They are notmerely modernized mental hospitals but are services that attend to very specific needsrequiring an institutional setting. Furthermore, they are not expected to provide primarymental health services to the general population but act as secondary and tertiary referralservices. They include acute and high-security units, specialist units for children andelderly people, and other specialist services such as forensic psychiatry units.Examples of these services are given in Box 4.
Human resources are easily available in most communities.
Informal services can play an important role in supporting formal mental health services.
They usually have high acceptability in local communities.
There are few access barriers.
They are not always free and users may have to bear some costs.
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Box 4. Examples of specialist institutional mental health services
> Specialist inpatient care- Medium-security units- High-security units
> Specialized units/centres for the treatment of specific disorders and for related rehabilitation programmes, e.g. eating disorder units
> Specialist clinics or units dedicated to specific mental disorders of children and adolescents
> Rehabilitation services for specific disorders of children and adolescents, e.g. autism and psychotic disorders
> Respite care
> Specialist clinics or units dedicated to specific disorders of the elderly, e.g. Alzheimer’s disease
Potential benefits and disadvantages of specialist institutional services in mental hospitals
I) Human resources: Specialist services require a large complement of trained specialistmental health staff. Shortages of such staff are a serious problem in developing countries.The absence of trained personnel can make it difficult to maintain the desired qualityof service and creates a risk of skewing the service towards custodial care with littletherapeutic input.
II) Clinical outcomes: Specialist services are usually tertiary referral centres. Patientswith mental disorders that are difficult to treat make up a large proportion of theircase-loads. The success of specialist services is highly dependent on the quality ofservices and infrastructure available to them. In developed countries, where many ofthese specialist services are well funded and well resourced, they provide care of highquality with sufficiently good outcomes to justify their continuation. In developing countriesthe lack of finances, infrastructure and personnel usually means that many of theseservices are absent or inadequate.
III) Acceptability: As with all segregated mental health institutions, specialist mentalhealth services are associated with social stigma and consequently may not be highlyacceptable. Service users are frequently reluctant to use these services except as a lastresort. This may not necessarily be a problem as specialist services are not expectedto encourage people to use them as first-line care providers.
IV) Access: Nearly all specialist services have problems of access both in developedand developing countries. Many of these services are not easily available, even in developedcountries, and are almost absent in developing countries. These specialist services arelocated in the vicinity of large urban areas but are frequently at some distance fromthem. Transport links to the hospitals in question may be inadequate, resulting in highcosts of access. Stigma associated with segregated mental health services provided byspecialist facilities acts as a barrier to use. Some of the access problems do not haveeasy answers. It is arguable, however, that specialist services should not be readilyaccessible services of first resort. For reasons of sustainability, moreover, specialistservices have to be centralized and access has to be limited by the requirement of aprofessional referral.
Shortages of human resources affect the quality of specialist services.
Specialist services help many patients with severe mental disorders that are difficult to treat.
Specialist services are not first-line care providers.
Specialist services have some problems with geographical access.
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V) Financial costs: The cost of setting up and running specialist services is high incomparison with that of other forms of service delivery. The reasons for this include thehigh level of investment required to set up dedicated units and the high staff costsassociated with low ratios of staff to patients. In addition, costs rise because institutionshave to care for individual patients over long periods of time. In many developing countriesthe cost of specialist units is not necessarily high because staff costs are lower than indeveloped countries, and investments are often at a low level as units function insubstandard conditions. It is difficult to evaluate the financial disadvantage of specialistmental health services in such circumstances. However, if specialist services of goodquality were provided in developing countries the above financial issues would applyequally to them. The exact distribution of these costs between service providers andservice users depends on the funding arrangements in particular countries. Even whensuch services are publicly funded the users incur the indirect costs of obtaining carefrom them.
2.3.2 Dedicated mental hospitals
These are old-style mental hospitals, mainly providing long-stay custodial services. In manyparts of the world they provide either the only mental health services or a substantialcomponent of such services. This may appear to contradict Atlas data indicatingthat only 37% of countries have no community care facilities, that 87% of countrieshave identified mental health as an activity in primary care, and that regular trainingof primary care personnel takes place in 59% of countries (World Health Organization,2001b). However, these percentages do not reflect population coverage. Thus India,with a population in excess of 1 billion, has a community mental health programme in22 districts covering a population of only 40 million (Jacob, 2001).
Potential benefits and disadvantages of mental hospitals
I) Human resources: In many countries, mental hospitals consume most of the availablespecialist mental health resources. This acts as a serious barrier to the developmentof alternative community-based mental health services. Moreover, there are high ratesof staff burnout and demotivation and there is a gradual decline in skills of mentalhealth professionals.
II) Clinical outcomes: Many of these institutions provide only custodial care of thekind found in prisons, frequently of extremely poor quality. Clinical outcomes are poorbecause of a combination of factors, e.g. poor clinical care, human rights violations, thenature of the institutionalized care process and a lack of rehabilitative activity. Highcosts and poor clinical outcomes mean that these institutions represent the least desirableuse of the scarce financial resources available for mental health services. This isparticularly true in developing countries where mental hospitals offer the only mentalhealth services.
III) Acceptability: Mental hospitals generally do not enjoy high acceptability amongpeople with mental disorders and communities. Significant stigma is associated withsegregated mental hospitals, and people are usually reluctant to use these servicesexcept as a last resort. This results in delays in seeking treatment from such services,which in turn adversely affects clinical outcomes. Mental hospitals in developing anddeveloped countries have a history of serious human rights violations. During the pasttwo decades this has led to either their closure or their comprehensive reform. In spiteof the improvements made, serious human rights concerns still surround the remaininglong-stay mental hospitals in developed and developing countries.
Specialist services of good qual-ity are costly because of heavyinvestment in infrastructure andstaff.
Mental hospitals consume a significant proportion of financial and human resources in many countries.
Clinical outcomes are poorbecause of the generally lowquality of service provided in many mental hospitals.
Mental hospitals are often associated with stigma andhuman rights violations.
There is a reluctance to use these services.
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IV) Access: Nearly all mental hospitals have problems related to access. They are usuallybased at some distance from urban areas and have poor transport links. People withmental disorders who are kept in these institutions may be isolated from their familiesbecause, for example, it is often very difficult to receive visitors or maintain contact withthe outside world. Access is also hampered by cumbersome procedures related toadmission and discharge and by the stigma associated with such institutions.
V) Financial costs: Mental hospitals are expensive and, in many developing countries,consume a significant portion of the budget meant for mental health services, leavingfew resources for community-based initiatives. In Indonesia, for example, 97% of themental health budget is spent on public mental hospitals (Trisnantoro, 2002). Many ofthe hospitals tend to be of a fixed nature with static long-stay populations of patients.
There are significant access barriers in most countries.
High financial costs leave few resources for alternative services.
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Key points: Mental health services
- Mental health services can be broadly categorized as: (I) mental health servicesintegrated into general health services; (II) community-based mental health services(III) institutional services provided by mental hospitals.
- Mental health services in primary care require significant investment in adequatehuman resources and appropriate training for primary care professionals.
- Good clinical outcomes for many mental disorders are possible through servicesdelivered in primary care settings.
- Mental health services in primary care enjoy significant advantages of access,acceptability and lower financial costs for both providers and users.
- Mental health services in general hospitals require the presence of trained mentalhealth professionals in sufficient numbers.
- Formal community mental health services need close working links with primarycare and with secondary and tertiary hospital-based services.
- There is usually a high degree of satisfaction with well-resourced community servicesamong users and their carers.
- The provision of community-based mental health services does not produceimmediate cost savings for service providers.
- Providers of informal community mental health services are a readily availableresource in many countries.
- Informal community mental health services are the first contact and sometimes theonly providers in many developing countries.
- Specialist hospital-based services are needed in most countries although theabsolute requirement for them differs between countries and is significantly lowerthan that for primary care and community-based mental health services.
- Dedicated mental hospitals are associated with stigma and human rights violationsin many countries.
- In many countries, dedicated mental hospitals consume a disproportionate amountof financial and human resources, with the result that little scope is left for thedevelopment of alternative services.
23
3. Current status of service organization
around the world
Very few countries have an optimal mix of services. Even within countries there areusually significant geographical disparities between regions.
Many countries rely on mental hospitals as the main providers of mental health care.These hospitals are usually located at a considerable distance from urban areas. This,along with poor transport facilities, emphasizes the segregation of people with mentaldisorders. The physical appearance of the hospitals is often menacing: many aresurrounded by high walls with sentry towers, reflecting the custodial nature of the careprovided. The institutions are often poorly equipped. Basic amenities such as toilets,beds and personal space for private belongings are often unavailable. Staff/patientratios may be very low. This makes it unlikely that patients will receive professionalattention of good quality on an individual basis. Human rights violations of all kindsare common. Box 5 contains an extract from a report of the National Human RightsCommission of India on the workings of the country’s mental hospitals. It provides agood insight into the nature of such institutions and the difficulty of reforming them inorder to overcome basic problems.
Box 5. Functioning of mental hospitals in India
The National Human Rights Commission of India investigated the 37 public mentalhospitals in India housing nearly 18 000 patients. A report on the investigation waspublished in 1999. The following information taken from the report highlights some ofthe gross human rights violations occurring in these institutions.
The overall ratio of cots (beds) to patients was 1:1.4 indicating that floor beds were acommon occurrence in many hospitals. Even in hospitals with cot to patient ratios of1:1, many of the cots had been sent for repair, with the result that patients had to sleepon cold damp floors.
In the male wards of the hospitals at Varanasi, Indore, Murshidabad and Ahmedabad,patients were expected to urinate and defecate into an open drain in public view.Toilets in many of the hospitals were badly clogged with faeces. There were no tapsin the toilets in some hospitals. Thirteen of the hospitals (35%) had very dirty toilets.
Many hospitals had problems with running water, often reflecting a scarcity of water in thestate concerned. Water storage facilities were poor in 26 of the hospitals (70.2%) and therewere associated water shortages. Patients sometimes had to go out of their wards in orderto obtain water. Safe drinking-water was not easily available in some hospitals. A sharedbucket of water was located outside each ward. During the night, when they were lockedup, the patients in many hospitals had to reach through the bars of the ward in order toscoop water into a shared mug. Some of the hospitals did not provide hot water forbathing, even during the winter. Open baths were common (i.e. there were no bath-rooms/washrooms and people had to take showers outdoors). Sixteen of the 37 hospitals(43.2%) had cells. In some hospitals, many patients were confined in a single cell. In others,there was one patient to a cell. Many single cells lacked water, linen, beds or toilets.Patients were locked in all the time and had to urinate and defecate in their cells.
Source: Quality assurance in mental health. New Delhi: National Human RightsCommission of India; 1999.
Human rights violations are still a significant problem in many mental hospitals in both developingand developed countries.
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Some developing countries have taken steps to make mental health services morewidely available by integrating them into primary care. Some other countries have alsomade mental health services available in general hospitals. Unfortunately, both ways ofproviding these services are only available to small proportions of the populations con-cerned, usually in urban centres or selected rural areas. There has been little concertedeffort to use primary care as the principal vehicle for the delivery of mental health serv-ices. Box 6 and Box 7 contain examples of integrated services. Box 8 contains exam-ples of geographical disparities in the provision of mental health services.
Box 6. Examples from various countries of mental health services in primary care
Argentina: In Neuquen Province, cooperation between primary care general practitionersforming part of the general health sector and consulting psychologists from the mentalhealth sector was hampered by different training paradigms. The general practitionersdesired more training in mental health issues and better coordination with consultingpsychiatrists and psychologists. The provincial health department responded by creatinga commission on mental health which, among other things, focused on constructing asound referral and consultation network and training primary care general practitionersand nurses in remote rural regions. In order to design an appropriate training programmethe commission convened a conference for general practitioners to which professionalswith diverse international experience and training in mental health issues were invited.There were representatives of nursing, psychiatry, primary care medicine, the clergy,social work, and law. The training team included people from Argentina, Chile,Guatemala, the United Kingdom, Uruguay, and the USA. After the training experiencethe mental health commission, which included representatives of the fields of mentalhealth and primary care, coordinated further training and long-term follow-up of boththe general practitioners and local psychologists in the primary care setting (Collins etal., 1999a). This approach to integrating mental health care into primary care operateson various levels. At the level of the provincial government there is cooperation betweenthe mental health and primary care sectors on the mental health commission. At theprimary care level there is wider intersectoral cooperation between different professionswith a stake in the issues. The training programme promotes cooperation between generalpractitioners, nurses and social workers in the context of providing support to families,and a similar training programme has been designed for nurses (Collins et al.,1999a). Inthe context of the consultative approach pursued at the primary care level, some generalpractitioners in rural regions meet every month with traditional healers to coordinate thetreatment of certain illnesses, enhance the degree to which communities trust generalpractitioners, and prevent dangerous dual treatments involving the use of herbs andmedications (Collins et al., 1999b).
China: General primary health care services are provided by outpatient clinics in street,neighbourhood or district general hospitals (Pearson, 1992; Yan et al., 1995). There arevarious community services at the primary care level. They include home beds with visitsfrom personnel attached to district or neighbourhood hospitals and nursing or supervisorycare groups organized at the street level and the residents’ association level (Pearson,1992). In Shanghai there are hot-line services for adolescents and the elderly (Ji, 1995).
Botswana: Psychiatric nurses based in secondary-level district hospitals oversee anumber of primary care clinics in each district. They visit these clinics regularly andmeet primary care workers who have identified vulnerable cases in the community(Ben-Tovim, 1987).
Primary care services are still not being used as the principal vehicle for service delivery in most countries.
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Guinea-Bissau: A well-functioning primary care system with an infrastructure and paidworkers was in place before the recent war. Nurses in the primary care health centreswere trained to identify and treat cases of major mental disorder presenting in clinics(De Jong, 1996).
India: The Bellary district project involved the training of all categories of primary healthand welfare personnel, the provision of essential psychotropic drugs, a simple record-keeping system, and a mechanism for monitoring the work of primary care personnelproviding mental health care services (Murthy, 1998). Primary care centres generallyprovide preventive and curative services for 30 000 people and have one or two doctorsand 15 to 20 basic health workers. The doctors in the clinics supervise the health workers,who visit families at home and carry out a wide array of health activities. Patients areseen in the centres without appointment. On average a consultation lasts between threeand five minutes. Despite all the inputs of mental health training there still appears tobe a relatively low recognition of emotional disorder by primary care doctors. This isattributable to patients presenting with somatic complaints and to the brevity of theconsultations (Channabasavanna et al., 1995).
Islamic Republic of Iran: Efforts to integrate mental health care started in the late 1980sand the programme has since been extended throughout the country. There are nowservices for about 20 million people (Mohit et al., 1999).
Pakistan: A model of mental health care delivery integrated into primary care wasinitially developed in two subdistricts of Rawalpindi (Mubbashar, 1999). It is now beingreplicated in parts of all provinces. The component of training in mental health has beenintegrated into the training programme of district health development centres. Thesecentres have been set up to build the capacity of primary care personnel so that theycan handle the emerging common health problems. Under this scheme more than 2000primary care physicians and more than 40 000 primary care personnel (including femalehealth workers and multipurpose health workers) have received training throughout thecountry in a decentralized manner. More than 65 junior psychiatrists have been trainedin community mental health so that they can act as resource persons in the developmentof community mental health programmes in their areas and provide the training, referraland evaluation support necessary for integrating mental health care into primary care.A national essential drug list has been formulated which includes all the essentialneuropsychiatric drugs. Another crucial development has been the inclusion of prioritymental disorders in the national health management information system. TheGovernment has agreed to fund the integration of mental health into primary care on anational scale and a separate budget has been allocated for this purpose.
Tanzania: Rural dispensaries are provided by public, private and voluntary sources.These facilities offer basic medical services in rural regions (Ahmed et al., 1996). Insome rural areas, agricultural rehabilitation villages provide sheltered employment,continuous contact with local community members, and ongoing psychosocial supportfrom traditional healers, community health workers, and general practitioners. Thesecommunity-based services provide an alternative to hospital inpatient services for long-termand medium-term patients (Kilonzo & Simmons, 1998).
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Box 7. Examples from various countries of mental health services in general hospitals
Ethiopia: The services at the tertiary level have collaboratively developed a programmeof mental health care at the secondary level by training psychiatric nurses. Twenty-seven regional hospitals and one health centre have opened psychiatric units, eachoperated by two psychiatric nurses (Alem et al., 1999).
Nepal: Secondary-level psychiatric units are located in district hospitals. The facilitiesat the secondary level include smaller psychiatric wards in the military hospital and tworegional hospitals, and a small community mental health programme at three otherregional hospitals. The mental health care units outside the capital do not includeservices for long-stay inpatients (Tausig & Subedi, 1997).
Tanzania: Community mental health care teams have been established in secondary-level clinics in the capital city but there are no such teams in rural areas. In both ruraland urban areas, secondary-level facilities are located in psychiatric units in districtgeneral hospitals (Kilonzo & Simmons, 1998).
Tunisia: Since 1956, 300 new psychiatric beds have been provided in small psychiatricunits in five general hospitals throughout the country, and the bed capacity of the onlymental hospital has been halved.
Box 8. Examples from various developing countries showing the concentration of mental health services in urban areas
Botswana: Specialized mental health services are found in the capital city and regionalcentres, while the rural regions rely for mental health services on primary care clinics,the visits of psychiatric nurses to these clinics, and traditional healers (Ben-Tovim, 1987;Sidandi et al., 1999).
Cambodia: Although 85% of the country’s population lives in rural areas there are fewmental health resources other than traditional healers in these areas. There are relativelyfew district mental health clinics in outlying regions. Patients often travel over 300kilometres from neighbouring districts and provinces in order to reach a clinic.
Costa Rica: Most mental health care workers are concentrated in urban settings.The rural regions are understaffed (Gallegos & Montero, 1999).
Ethiopia: All tertiary psychiatric institutions are based in the capital city, as are mostpsychiatrists. The regional hospitals with psychiatric units are in both urban andrural regions. There are plans to extend the psychiatric service to more districthospitals and health centres in the rural regions. There are no mental health servicesin primary care clinics in either urban or rural settings. Traditional healers meet themental health needs of rural communities. It is common practice for people in ruralregions to care for family members with mental disorders at home (Alem et al., 1999;Awas et al., 1999).
Former Eastern Bloc countries: Mental health services are still organized by centralplanning bureaucracies and there is a clear demarcation between local and centraladministration. Authority resides at the centre, i.e. the urban centres. Remote rural areasare forced to supply services conceived and financed by the central bureaucracy(Tomov, 1999).
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Nigeria: Urban hospitals have more medical personnel and their support facilitiesfunction more efficiently than government hospitals in rural areas (Gureje et al., 1995).
Pakistan: There are residential and day care facilities for people with learning difficultieswhich provide social, vocational and educational activities in the big cities. However,these services are not accessible to the vast majority of rural people (Yousaf, 1997).
South Africa: There are almost 500 registered psychiatrists, but because of factorssuch as emigration and preferences for working in urban areas and the private sectorthere are areas of the country, indeed whole provinces, where there is only one psychiatristfor over 5 million people in the public sector.
Tanzania: In the rural areas the ratio of Western-trained doctors to the population is1:20 000 while that of traditional healers to the population is 1:25. In these areas,primary mental health care still relies on medical officers, mental health nurses andauxiliaries. Psychiatrists are found only in the major urban centres with regional psychiatricfacilities. The imbalance in the numbers of mental health professionals between urbanand rural areas is also reflected in the presence of community mental health care teamsin the capital city and their absence from rural areas.
In some countries there are good examples of intersectoral collaboration betweennongovernmental organizations, academic institutions, public sector health services,informal mental health services and users, leading to the development of much-needed community-based services. At present such activities are limited to smallpopulations in urban areas; the vast majority of rural populations have no access tosuch services. There is an urgent need to encourage such activities as they can providemental health services in a manner that is acceptable to local communities. Box 9 containsexamples of such intersectoral collaboration.
Box 9. Examples of intersectoral collaboration from various countries
Cambodia: There is intersectoral cooperation between external donors and mentalhealth services at the tertiary level. The Canadian Marcel Roy Foundation for theChildren of Cambodia funded a children’s mental health clinic at the tertiary mental hospital,while the International Organization for Migration supported by the Norwegian Councilfor Mental Health initiated a project for training doctors as psychiatrists.
Czech Republic: The FOKUS association for mental health care involvesintersectoral cooperation. This service provider has become a nongovernmentalorganization, which allows it to receive government funds and private donations.FOKUS obtains funds from the Ministries of Social Affairs, Health, and Culture, theLabour Office, and the Prague Municipal Government, as well as from foreign and localprivate donor organizations. (Holmes & Koznar, 1998).
Ethiopia: Intersectoral cooperation takes place at the national level between theMinistry of Health, the University Department of Psychiatry and WHO. These bodiesbegan a training programme for psychiatric nurses in 1986 (Alem et al., 1999).
Israel: Regional mental health boards headed by psychiatrists are responsible forsupervising, coordinating and developing all mental health services and the collectionof all information on mental health in each region. Each board works with a regionalcoordination committee that includes representatives of central government, insurers,voluntary agencies, providers and service users (Tyano & Mozes, 1998).
Nongovernmental organizations can play an important role in service provision.
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Romania: The Ministry of Health and Ministry of Education launched a programmein 2001 to promote health education in schools, in which mental health issues are wellrepresented.
Tanzania: Psychiatric agricultural rehabilitation villages encapsulate an intersectoralresponse by local communities, the mental health sector and the traditional healingsector to the treatment and rehabilitation of people with severe mental disorders in ruralareas. Patients and relatives live with a village population of farmers, fishermen andcraftsmen and are treated by both the medical and traditional healing sectors. There areplans for a more formal collaboration between the traditional healing and mental healthsectors, as the former could play an increased role in managing stress-related disordersin the community. Traditional healers have participated in community mental healthtraining programmes and have shared their knowledge and skills in the managementof patients with mental disorders. Plans to increase communication between thetraditional healing and mental health sectors involve holding regular meetings andseminars (Kilonzo & Simmons, 1998).
Zimbabwe: The Harare City Health Department and the University of ZimbabweMedical School are collaborating in a research project, in connection with which membersof the community and primary care nurses are looking for ways of treating depressedwomen. Local terminology for depression and ideas on treatment were established byinterviewing traditional healers and key community figures including schoolteachers,police officers, church officials and organizers of women’s cooperatives. Health workersthen presented the results of a survey of depressed women to community membersand coined a local phrase to describe the typical pattern of symptoms of depression.The participants, who included community members, health workers and policy-makers,were divided into working groups and asked to develop recommendations for treatingdepressed women. They recommended that: 1) there should be a private room in primarycare clinics for counselling on emotional problems; 2) a directory should be created toimprove communication between helping agencies; 3) traditional healers, church leaders,teachers and the media should be used to provide education for living; 4) the detectionand treatment of depression in primary care clinics should be improved (Abas et al.,1995). The programme of identification and treatment at the primary care level wasintegrated with a pre-existing highly developed initiative, viz. a maternal and child healthprogramme that involved cooperation between the mental health sector and the generalhealth sector. A more general mental health package was also integrated into the primarycare system in Harare on the basis of a similar cooperative approach. Consultationsbetween key health providers, policy-makers, academics and nongovernmentalorganizations occurred at the city level and a multidisciplinary research team wasformed. The objective was to identify the mental disorders that occurred most frequentlyamong persons attending for primary care, in order to develop guidelines for understandingand treating them at this level. The project involved collaboration between psychiatrists,social scientists, primary care workers, traditional and faith healers and generalpractitioners (Abas et al., 1995; Patel, 2000).
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Developed countries rely less on mental hospitals to provide mental health care. Theprocess of deinstitutionalization in the last three decades has led to a reduction in thenumbers of patients in mental hospitals and the closure of many of these institutions.However, a different set of problems remains in these countries. The deinstitutionalizationprocess has not been accompanied by a sufficient provision of community-basedresidential and occupational facilities (Thornicroft & Tansella, 1999). National constitutionalstructures and funding pathways of health systems have impacted on both the rate ofdeinstitutionalization and the provision of alternative community mental health servicesin various developed countries (Goodwin, 1997). Deinstitutionalization in North Americanand Western European countries leads to a gradual provision of community mentalhealth services. However, these services are often inadequate and unevenly distributednationally.
Even in developed countries there is insufficient emphasis on developing mental healthservices in primary care. For example, depression is a common problem in primary caresettings but is still not identified or is undertreated by primary care practitioners in manysuch countries. There is also an emphasis on developing more specialist services, e.g.forensic services, to the detriment of general hospital-based psychiatric services.For example, in the United Kingdom there has seen a vast expansion of medium-security beds in the last few years while there is a shortage of acute general psychiatricbeds and the occupancy rate is nearly 100% in many of these general psychiatricunits. See Box 10 for a summary of some of the advantages and disadvantages ofdeinstitutionalization.
Box 10. Advantages and disadvantages of deinstitutionalization in developed countries
Advantages- Deinstitutionalization involves a shift in emphasis from custodial accommodation torehabilitation programmes in community settings. It is more humane in that it avoids thedetrimental psychological effects of long-term hospitalization and focuses on patientsbecoming reintegrated into community settings.- It involves the prevention of new admissions by providing alternative communityservices and programmes that are supposedly cheaper to run. It thereby promotesefficiency and cost-effectiveness.- It involves the release into the community of all institutional patients who havereceived adequate preparation. This avoids the detrimental effects of long stays suchas apathy and loss of interest, and also cuts the cost of supporting patients in hospitalsettings for long periods of time (Thornicroft & Tansella, 1999).
Disadvantages- Deinstitutionalization has often not resulted in the securing of adequate long-termfunding for the maintenance of public mental health services in community settings(Talbott, 1978; Goodwin, 1997). - While leading to an overall decrease in the long-stay inpatient population, deinstitu-tionalization has resulted in increasing numbers of readmissions, i.e. multiple short-termstays for specific patients requiring inpatient treatment (Talbott, 1978; Breakey, 1996a).- In some instances it has led to an increase in homelessness among persons withmental disorders and to a high rate of mental disorder in prison populations.
Even in developed countries, de-institutionalization has not been accompanied by an adequate provision of services in the community.
There is significant potential for using primary care services, even in developed countries.
30
Two main conclusions can be drawn from the experiences that have been gained.
- Firstly, mental health services pose a challenge for both developing and developedcountries. However, the nature of the challenges differs. In many developing countriesthere is gross underprovision of resources, personnel and services. This state of affairsrequires immediate attention. In developed countries some of the problems are: insufficientcommunity reprovision; the need to promote the detection and treatment of mentaldisorders in primary care settings; the competing needs and demands of generalpsychiatric services and specialist services.
- Secondly, more expensive specialist services cannot provide a solution to theseproblems. Even within the resource constraints that health services confront in nearlyall countries, significant improvements in the delivery of mental health services canbe achieved by redirecting resources towards services that are less expensive, havereasonably good outcomes, and benefit larger proportions of populations. In practicethis means emphasizing the delivery of mental health services through primary care.
Key points: Current status of service organization
- Very few countries have an optimal mix of services.
- In many countries there have been few concerted efforts to use primary care as theprincipal vehicle for the delivery of mental health services.
- Innovative service provision involving collaborative efforts of many sectors existsin many countries but is usually limited to small populations in urban areas or selectedrural areas.
- In developed countries the process of deinstitutionalization has not always beenaccompanied by a sufficient provision of alternative community-based services.
- Mental health services pose challenges both for developing and developed countriesbut the nature of these challenges differs.
- More expensive and/or specialist services are not necessarily the answer to increasingaccess to and availability of mental health services.
The nature of the problems differs between developed and developing countries
An increase in specialist services will not necessarilyimprove access to mental health care.
31
People with mental disorders have complex needs which frequently cut across the traditional professional sectors.
Special attention should be given to the development of comprehensive and integrated systems of service delivery.
Systems of service delivery can be arranged around key principles.
4. Guidance for organizing services
No single model of service organization can meet the needs of all countries. Therecommendations outlined in this section are broad principles that are likely to beapplicable in most countries. Each country should adapt them to its own circumstances.
People with mental disorders often have a complex range of needs that cannot befulfilled by the health services alone. Furthermore, different stakeholders in this field arelikely to have particular perspectives that can usefully inform the development of services.People with mental disorders, their families and communities are equal partners withmental health services, and it is important that all of these stakeholders should activelycommunicate and collaborate with each other so as to meet the needs under consideration.Health care settings and levels of care should be organized in a way that fulfils this goal(World Health Organization, 2001).
4.1 Principles for the organization of services
The recommendations given below should be seen as a part of a comprehensivereorganization of services. None of the individual recommendations can succeed on itsown in improving the care of people with mental disorders. The emphasis is on anintegrated system of service delivery which attempts to comprehensively address thevarious needs of people with mental disorders. In such a system each of the distinctchannels of service delivery, e.g. services in primary care and services based in generalhospitals, has an important and complementary role with respect to the others. It isnecessary to provide a range and variety of services that can meet needs that arise atdifferent times.
Failure is likely, for example, if a strategy is adopted whereby primary care staff areencouraged to perform interventions without making adequate provision for secondarycare services or community services in the field of mental health. None of the strategiesfor service reorganization discussed below can stand on its own. Each strategy needssupport and in turn will support other parts of an integrated service delivery system.
The key principles for organizing services are discussed below.
I) Accessibility: Essential mental health care should be available locally so that peopledo not have to travel long distances. This includes outpatient and inpatient care andother services such as rehabilitative care. An absence of services locally acts as asignificant barrier to obtaining mental health care, especially for people living in remoterural areas. Services located close to persons with mental disorders can provide continuityof care in a comparatively satisfactory manner. It is difficult to address many social andpsychological issues when people have to travel long distances in order to contactmental health services.
II) Comprehensiveness: Mental health services should include all facilities and programmesthat are required to meet the essential care needs of the populations in question. Theexact mix of services required varies from place to place. It depends on social, economicand cultural factors, the characteristics of disorders and the way in which healthservices are organized and funded (see Section 6.2).
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III) Coordination and continuity of care: Especially for people with severe mentaldisorders it is extremely important that services work in a coordinated manner andattempt to meet the range of social, psychological and medical care needs. Thisrequires input from services that are not directly related to health, e.g. social servicesand housing services. Persons with mental disorders often find it extremely difficult togain access to various essential services, with the result that poor outcomes occur.Mental health services should therefore perform a coordination function and prevent thefragmentation of care (see Section 7.2).
One way of addressing the need for continuity of care is to apply the sectoral or catchmentarea method of organizing services. During the 1960s and 1970s, health departmentsin North America and Western Europe divided their countries into health districts orcatchment areas, i.e. they defined geographical areas with populations of between 50000 and 250 000 (Breakey, 1996b; Thornicroft & Tansella, 1999). Catchment area healthcare teams covered all levels of service provision, i.e. primary, secondary and tertiarycare, and were responsible for the provision of health care services for all the inhabitantsof the areas concerned. Apart from the planning, budgeting and management advantagesof this approach, one of the key clinical advantages is that there is an enhancedlikelihood of providing continuity of care. This is of enormous benefit as many mentaldisorders tend to be long-lasting and require ongoing care for substantial periods.
IV) Effectiveness: Service development should be guided by evidence of the effectivenessof particular interventions. For example, there is a growing evidence base of effectiveinterventions for many mental disorders, among them depression, schizophrenia andalcohol dependence. This evidence is reviewed in Section 7.1. (See also World HealthOrganization, 2001a.)
V) Equity: People’s access to services of good quality should be based on need. Inorder to ensure equity it is necessary to address issues of access and geographicaldisparities. Equity should be taken into consideration when priorities are being set. Alltoo often the people most in need of services are the least likely or the least able todemand services and are thus likely to be ignored when priorities are being set.
VI) Respect for human rights: Services should respect the autonomy of persons withmental disorders, should empower and encourage such persons to make decisionsaffecting their lives and should use the least restrictive types of treatment.
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4.2 Establishment of an optimal mix of services
Nearly all the service delivery models discussed in Section 4 have both strengths andweaknesses. The key issue for service planners is to determine the optimal mix ofservices and the level of provision of particular service delivery channels. The absoluteneed for various services differs greatly between countries but the relative needs fordifferent services, i.e. the proportions of different services as parts of total mental healthservice provision, are broadly the same in many countries. Services should be plannedin a holistic fashion so as to create an optimal mix.
Figure 2 shows the relationships between the different service components. It is clearthat the most numerous services ought to be self-care management, informal communitymental health services and community-based mental health services provided by primarycare staff, followed by psychiatric services based in general hospitals and formalcommunity mental health services, and lastly by specialist mental health services. Theemphasis placed on delivering mental health treatment and care through servicesbased in general hospitals or community mental health services should be determinedby the strengths of the current mental health or general health system, as well as bycultural and socioeconomic variables.
There is little justification for including the kind of services provided by mental hospitalswhen consideration is being given to the optimal mix of services. Mental hospitalsessentially provide long-stay custodial care. With the development of a range ofcommunity-based services and specialist services there is no need for mental hospitals.There will always be a need for long-stay facilities for an extremely small proportion ofpatients, even if there is good provision of community-based services. However, mostof these patients can be accommodated in small units in the community, with anapproximation to community living as far as is possible. Alternatively, small long-staywards in hospitals can also provide other specialist services. (See also Planning andBudgeting to Deliver Services for Mental Health.) Large-scale custodial institutional careas provided by mental hospitals is not justified either by its costs, its effectiveness orthe quality of care provided.
Planners should provide a range of services.
Services should be planned in a holistic fashion so as to create an optimal mix.
With the development of a range of community-basedand specialist services there is no need for mental hospitals.
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Self Care
Informal Community Care
Mental Health Servicesthrough PHC
Long-StayFacilities
&SpecialistServices
PsychiatricServices inGeneralHospitals
CommunityMentalHealth
Services
low
high
high
low
FREQUENCYOF NEED
QUANTITY OF SERVICES NEEDED
COSTS
Figure 2: Optimal mix of different mental health services
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4.3 Integration of mental health services into general health services
In order to overcome the difficulties associated with segregated services it is necessaryto integrate mental health services into general health services. Integrated care helps toreduce the stigma associated with seeking help from stand-alone mental health services.In developing countries with acute shortages of mental health professionals the deliveryof mental health services through general health care is the most viable strategy forincreasing access to mental health care among underserved populations. Furthermore,mental disorders and physical health problems are very closely associated and ofteninfluence each other. For example, people with common mental disorders such asdepression and anxiety frequently present with somatic symptoms to general healthcare services. An integrated service encourages the early identification and treatmentof such disorders and thus reduces disability. Other potential benefits include possibilitiesfor providing care in the community and opportunities for community involvement in care.
Integration can be pursued at all levels. At the clinical level, mental health care can beintegrated into the primary, secondary and tertiary levels of general health care. Thismay be accompanied by managerial and administrative integration as well as thedevelopment of integrated information systems. (See also Planning and Budgeting toDeliver Services for Mental Health.) For example, mental health professionals working inthe general health care system may have a management structure (line management)that is quite separate from that of the general health staff. This occasionally createsdifficulties in their day-to-day working and in their relationships with colleagues inthe general health system. Managerial integration can help to resolve some of theseissues.
Information systems for general health are separate from mental health informationsystems in many countries. This creates difficulties for planners and managers in thegeneral health system because they plan services without appreciating the burden ofmental disorders. The integration of mental health information systems with generalhealth information systems can improve the total health situation in a country. It canalso help advocate for better mental health services by making the substantial burdenof mental disorders obvious to health planners. However, some information specificto mental health should be available in order to enable the appropriate planning andevaluation of mental health services. This may require the modification of general healthinformation systems so as to include the recording of mental health service provisionand attendance by people with mental disorders.
Full integration, involving clinical, administrative, managerial and information systems,has certain drawbacks. Mental health services may prefer to retain a degree of separation,e.g. separate management structures at lower management levels. A degree of separationmay help to protect budgets for mental health care and to preserve the professionalidentity of mental health staff.
When choosing between full and partial integration, countries should assess the potentialbenefits and disadvantages of each and should take account of the way in which primarycare services are organized. In most situations, strategic planning for service integrationis necessary (Box 11).
Integrated care helpsto reduce stigma, addressesshortages of humanresources and improvesaccess to mental healthservices for underservedpopulations.
Full integration has its advantages and drawbacks
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Box 11. Strategic planning for the integration of mental health services
Major issues in strategic planning include the following:
(I) Working out how the mainstreaming of mental health into the general health delivery system is to be carried out. This involves setting out organizational changes and delineating responsibilities.
(II) Budgeting for new posts, physical facilities, equipment and transport.
(III) Planning for mental health teams and their responsibilities.
(IV)Preparing job descriptions for various professionals and supporting staff at each level of care, e.g. primary care workers, mental health care workers, and supervisors, and specifying their responsibilities in connection with the coverage of the various mental health conditions that are being targeted.
(V) Planning for: the institutional training of personnel requiring skills; on-the-job training; continuing medical education; the insertion of mental health material into the curricula of health and health-related training institutions.
(VI)Strategies for mobilizing and involving community members and consumers at every level of activity.
At a basic level, integration into general health care involves:
- the integration of mental health services into primary care settings;- the integration of mental health services into general hospitals; - the development of links between primary care and secondary
services based in general hospitals; - the integration of mental health care into other established health
and social programmes.
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4.3.1 Integration of mental health services into primary care settings
In countries with limited resources the integration of mental health care into the generalhealth delivery system necessarily involves integration into primary care. First andforemost this requires the training of primary care staff. Primary care workers have toassume increasing responsibilities for the promotion of mental health and the provisionof mental health services. Health workers in training institutions and those already in thefield have to be oriented towards the provision of services in the primary care setting.They also have to be equipped with knowledge and skills enabling them to provide suchservices. Primary care workers may resist taking on these roles. For example, they mayquestion their role in managing mental disorders. They may be uncomfortable aboutdealing with mental disorders or they may ignore and withdraw from working with peoplewho have such disorders. Clinical outcomes, which are highly dependent on theknowledge and skills of primary care staff, would consequently be unsatisfactory.Furthermore, the acceptability of the service would be reduced if poorly trained staffignored mental disorders or did not pay equal attention to mental and physical disorders.Solutions to these problems are considered in Section 9.
Primary care workers should be prepared to take part in this process. Their tasks,obligations and responsibilities should be outlined as they participate actively in them.They should be trained in the promotion of mental health and in the prevention andmanagement of priority mental disorders. The training should include all categories ofhealth workers and other workers whose work touches on the mental health of the com-munity, e.g. security officers and receptionists in health facilities.
The training materials should include appropriate selections from those suggested forthe planning team at the national level as well as other materials available locally ordeveloped for the programme in question in order to meet the specific needs of thecommunity. A guide on such training is available (World Health Organization, 1982).
The time factor has to be considered if primary care staff are to devote themselvesadequately to mental health work. Primary care staff are overburdened in many countries,being expected to deliver multiple health care programmes that are mainly concernedwith physical disorders. In such situations it is necessary to increase the numbers ofprimary care staff so that they can take on additional mental health work. (See Planningand Budgeting to Deliver Services for Mental Health.)
Primary care staff have to be adequately supervised if integration is to succeed. Mentalhealth professionals should be regularly available to primary care staff to give advice onthe management and treatment of people with mental disorders. Regular supervisioncannot be replaced by a system of referral to secondary and tertiary care. The absenceof supervision can lead to a high rate of such referral for even minor problems that couldbe dealt with by primary care staff if they were supervised on site. A member of themental health team in the secondary care services could visit the primary care team ona weekly or fortnightly basis to provide supervision. The mental health professionalshould be available to discuss difficulties in management and to provide advice oninterventions to be carried out by primary care staff. This model of supervision hasworked well in India (Murthy, 1998).
Other issues that need to be addressed include the provision of an adequate infrastructure,the availability of equipment and, most importantly, the availability of psychotropicmedication. The delineation of a few targeted mental disorders to be treated at the primarycare level simplifies the requirements for types of medicines. A list of medicines canbe drawn up in accordance with WHO recommendations on essential drugs at variouslevels of care. All major categories can be made available at all levels, with a narrowerrange of choices at the primary care level. Bulk purchasing of generic medicines
Primary care staff need training and skills in order to be able to treat mental disorders.
More primary care staff are needed in many countries if integration is to succeed.
The infrastructure and human resources must be adequate if integration into general health care is to succeed.
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ensures low costs and continuous supplies throughout the year. This approach alsosimplifies training, as primary care workers only need to be proficient and skilled in theuse of a few selected drugs. (See Planning and Budgeting to Deliver Services for MentalHealth and Mental Health Financing.)
4.3.2 Integration of mental health services into general hospitals
Mental health services based in general hospitals can provide secondary-level care topatients in the community and services to those who are admitted for physical disordersand require mental health interventions. Integration into general hospitals requires facilitiesand human resources. (See Planning and Budgeting to Deliver Services for MentalHealth.) The required facilities include beds for the management of acute mental disorders,outpatient facilities, equipment for specialized tests, e.g. psychological tests, equipmentfor specialized treatments, and medication.
The required human resources include specialist mental health staff such aspsychiatrists, psychologists, psychiatric nurses and social workers. These staff haveto take responsibility for the training and supervision of primary care workers.Some of these specialist staff may not be sufficiently oriented towards primarymental health care and community-based service delivery and will themselvesrequire training.
4.3.3 Establishment of links between primary, secondary and tertiary care
Primary health care is both an entry point and a referral point for mental health care andprevention. In order to address the needs of persons with mental disorders for healthcare and social support a clear referral and linkage system should be in place. It shouldbe operated in consultation with the district and regional levels. Regular meetings ofservice providers should be held in order to review and improve the referral system andto evaluate how the needs of patients are being met.
Even where specialist mental health services are well developed it is important toimprove coordination between them and primary care. If this is not done, care is oftenduplicated or poorly coordinated and delays occur when primary care workers seekhelp with patients in crisis.
4.3.4 Integration of mental health care into other established health and social programmes
In developing countries, other basic health priorities compete with mental health forfunding. (See Mental Health Policy, Plans and Programmes.) Instead of competing, mentalhealth programmes should collaborate with other health programmes. For example,programmes aimed at tackling maternal depression can usefully become part of a widerreproductive health programme. HIV/AIDS programmes offer another opportunity to increasethe coverage of mental health services to vulnerable populations. Such collaborativeapproaches should also be extended to programmes that are not directly related tohealth, e.g. women’s mental health issues could be covered in programmes tacklingdomestic violence.
4.4 Creation of formal and informal community mental health services
Formal community mental health services are the community counterpart of secondarycare services based in general hospitals. These include, for example, day centres forpersons with severe mental illness who have been discharged from hospitals, hospitaldiversion programmes, crisis teams, group homes, halfway houses and case managementservices. More examples of formal community services are given in Box 12. For many
Links between primary care and other levels of health care are essential.
Integration with other healthand social programmes may help to overcome resource difficulties.
Formal community mentalhealth services are thecommunity counterpartof secondary care servicesbased in general hospitals.
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developing countries it will not be immediately possible to develop all these services. Insuch circumstances, planners should decide which services are immediate prioritiesand should concentrate efforts and resources on developing them. Other services maybe developed in a phased manner over time.
In many developing countries, moreover, some of these community-based services,e.g. halfway homes or group homes, may not be needed to the extent that they arerequired in developed countries because of the availability of good family support. Thisis not to suggest that families should bear the entire burden of caring for persons withsevere mental disorders. However, community services should be designed to supportfamilies in their attempts to care for relatives with mental disorders.
Developing countries should also use existing networks of nongovernmental organizationsin order to provide some community-based services. These may include clubhouses,support groups, employment or rehabilitation workshops, sheltered workshops, supervisedwork placements, and staffed and unstaffed residential accommodation. Examplesfrom Tanzania and Zimbabwe (Box 9) illustrate the use of available resources to providecommunity-based services. Boxes 12 and 13 provide other examples of the use of formalresources, e.g. nongovernmental organizations, and informal resources, e.g. neighboursand religious leaders, for providing community-based services.
Box 12. Innovative formal and informal community mental health services
China: Psychiatric care units consist of patients’ neighbours, retired workers, and familymembers who assist with the care of mental patients (Pearson, 1992).
China, India, and Malaysia: Governments contract with nongovernmental organizationsto provide care for childless elderly people in small residential homes (Levkoff et al., 1995).
India: Teachers are trained as counsellors in order to provide therapeutic interventionsfor children in schools (Nikapota, 1991). Lay volunteers provide crisis intervention servicesin some of the major Indian cities (Murthy, 2000).
Mongolia: Community-based day centres in traditional Mongolian tented and portableround houses called gers were started in 2000 on the grounds of district health centresin the Songinokhairkhan and Chingletei Districts of Ulan Bator. The most significantachievement in Chingletei was the setting up of a canteen in the day centre for use bymedical and dental staff. The staff constructed benches and tables from broken furnitureand used old crockery and cutlery from the hospital or from their own homes in settingup the canteen. Notwithstanding the significant stigma and exclusion faced by personswith mental disorders in Mongolia, medical and nursing staff of this health centre willinglyate in the canteen (World Health Organization, 2000).
Families are an importantresource and they need active support from community services.
Nongovernmental organizations are another useful resource.
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Box 13. Meeting mental health needs in underresourced settings: innovations of nongovernmental organizations in India
Nongovernmental organizations have gained considerable experience in health care inIndia, notably in reproductive and child health services and research. In recent years agrowing number of nongovernmental organizations have begun to develop innovativeprogrammes for mental health care. In 1999 an attempt to coordinate nongovernmentalorganizations working in mental health programmes identified more than 50 initiativesacross the country. The most common ones involved rehabilitation, the empowermentof persons with severe mental disorders, and the provision of schools for children withmental retardation. However, the range of nongovernmental organizations has grownconsiderably in keeping with a growing awareness of the breadth of problems associatedwith mental disorders, e.g. substance abuse, mental disorders in children, dementiaand violence. The four nongovernmental organizations profiled below work in differentareas of mental health, integrate research, training and service delivery, and collaborateactively with other sectors of the health and social welfare systems. All have relied onfunding from a range of sources including individual and corporate donors, foundations,donor agencies and the Government.
The Schizophrenia Research Foundation, located in the southern city of Chennai, isone of India’s best-known providers of comprehensive integrated services for personsaffected by severe mental disorders. It was founded in 1984 by medical professionalsworking in a local medical school. It now provides community, outpatient, day care andresidential care services for patients with severe mental disorders, including a rangeof psychosocial rehabilitation services. It plays a leading role in advocacy for therights of persons with mental disorders, particularly for the formal acknowledgementof the disability produced by mental illness. It is one of the country’s leading agenciesconducting research into all aspects of schizophrenia. Its Madras Longitudinal Study isthe most widely cited study of its kind on the outcome of schizophrenia in a developingcountry. The Foundation is a WHO Collaborating Centre for Research and Training inMental Health.
The Sangath Society is located in the state of Goa on the west coast of India. Itwas founded in 1996 by a team of health professionals working in the field of child andadolescent development. In five years it has become the leading provider of community-based multidisciplinary child and family guidance services in the region, with more than350 referrals a year. The Society has extended services from the clinic to the communitywith programmes aimed at improving child development outcomes, e.g. early interventionfor high-risk babies, and to schools with programmes for improving awareness andteaching methods for children with different abilities. It actively collaborates withgovernment departments, academic institutions and other nongovernmental organizationswith a view to maximizing the potential for development of every child. It is a leadingagency for research on women’s mental health and adolescent health, and has alsobeen the coordinating agency for the country’s largest randomized control trial on thetreatment of depression in general health care.
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The T.T. Ranganathan Clinical Research Foundation was founded in 1980 by a womanwhose husband had suffered gravely from the consequences of a severe alcoholaddiction. This Foundation has pioneered a range of programmes for combating alcoholaddiction, with services delivered at every level of care from the community to a fullyequipped hospital. The Foundation’s major innovation has consisted of outreach campsthat are run for periods of two weeks to provide services for alcohol dependence in ruralareas. Services are thus taken directly to communities, and individuals are not expected totravel to distant cities for specialized care. The Foundation’s TTK Hospital, providing arange of medical and psychological therapies for alcohol dependence, has treated over10 000 patients since its inception in collaboration with the United Nations Drug ControlProgramme. The hospital was recently recognized by WHO as a Regional ResourceTraining Centre.
Ashagram is a nongovernmental organization located in the Barwani District of the stateof Madhya Pradesh in Western India. This is one of the poorest regions in the country,with high levels of illiteracy, severe environmental degradation and a large tribal population.Ashagram was founded in the 1980s by lay persons as a resettlement colony forpeople disabled by leprosy. Since then it has become a vibrant community with primaryeducation, comprehensive health care facilities and diverse income-generating units.Mental health services were initiated in 1996 for persons with severe mental disorders.The community participatory model was used to ensure that services were accessibleand in keeping with local cultural norms. The organization was largely run by mentalhealth workers from local villages who had received a basic education. The programmeon mental health was run alongside services for persons with physical disabilities. Whenit was necessary for a person with a mental disorder to be admitted to hospital, therefore,he or she would enter a ward used by other patients. The mental health programme hasnow been extended to cover common mental disorders.
Source: Patel V, Thara R, eds. Meeting mental health needs in developing countries:NGO innovations in India. Sage India (in press).
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De-institutionalization is not an immediate event but a planned process.
De-institutionalization should be preceded by the development of alternative community-based services.
4.5 Limitation of dedicated mental hospitals
Mental hospitals are expensive to run and maintain. They produce poor clinical outcomes,they are associated with increased rather than decreased disability, they stigmatizepatients, families and all people with mental disorders and they are associated withviolations of human rights. It is therefore important to reduce dependence on mentalhospitals as providers of mental health care. Deinstitutionalization is consequently anecessary part of reforming the delivery of mental health services.
However, deinstitutionalization does not simply mean discharging people from long-stayhospitals. It is a process involving significant and systematic changes whereby thedelivery of services becomes predominantly community-based rather than institutional.Community provision of services has to go hand-in-hand with reducing the numbers ofpeople in mental hospitals. In the long run the savings from the closure of mental hospitalscan be expected to compensate for increased expenditure on community-based services.In the transition period, however, services have to incur double running costs. (SeeMental Health Financing.)
Deinstitutionalization has to address the potentially negative effects of transferringfunctions of the traditional mental hospital into the community. These are described inBox 14. In addition, the following activities and services should be in place beforepatients are transferred from hospitals to communities.
I) Mental health services should be available in primary care facilities. This requires the training of family doctors, nurses and other primary care workers to identify and treat mental disorders.
II) Beds, facilities and specialist staff should be provided in general hospitals or in the community for the management of acute relapses requiring short-term hospitalization.
III) Staff in existing mental hospitals should be retrained to take up positions in general health care settings, including the supervision of primary care staff and the provision of mental health services in general hospitals.
IV)Psychotropic medication should be available in primary care and general hospital settings.
V) Formal and informal community mental health services should be introduced in order to help with community rehabilitation.
Once the above community-based alternatives are in place, deinstitutionalization canproceed in the following stages.
I) As a first step, all new admissions to mental hospitals should be stopped and the patients concerned should be directed to psychiatric units in general hospitals.
II) It is necessary to work with the families of patients due for discharge in order to provide both the families and the patients with help and support when discharge occurs.
III) Discharge should begin with the least disabled patients and should gradually move on to patients with increasing degrees of disability.
A minority of patients with severe mental disorders and severe disability require supervisedsupport for 24 hours a day. These patients can also be moved into small community-based residential units with 24-hour nursing and other staff supervision if these areavailable.
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Deinstitutionalization requires strong commitment on the part of planners, managersand clinicians. Moreover, agreement is necessary among all the stakeholders regarding thepace and timing of the process. Experience gained in Brazil shows that deinstitutionalizationcan succeed even if resources are limited (Box 15). Experience gained in the UnitedKingdom shows that community-based care for long-stay institutional patients canenhance their quality of life if there is a well-planned and well-resourced reprovisionprogramme (Leff & Treiman, 2000). Service providers can be provided with financialincentives for meeting time-bound targets in both the development of alternativecommunity services and the discharge of patients from long-stay institutions. Such financialincentives include increased budgetary allocations for community-based services, theprovision of additional finances for the community resettlement of long-stay patientsfrom institutions, and incentives offered to community mental health agencies for reducingbed usage. (See Mental Health Financing and Planning and Budgeting to Deliver Servicesfor Mental Health.)
Box 14. Effects of transferring functions of the traditional mental hospital to community care
Functions of traditional mental hospitals Effects of transfer to community care
Physical assessment and treatment More appropriate treatment in primary careor general hospital health services
Active treatment for short-term Treatment maintained or improved butand intermediate stays results may not be generalizable
Long-term custody Usually improved in residential homesfor those who need a high level of long-term support
Protection from exploitation Some patients continue to be vulnerable to physical, sexual and financial exploitation
Day care and outpatient services May be improved if locally accessible services are developed, or may deteriorateif they are not; negotiation of responsibilities is often necessary betweenhealth and social care agencies
Occupational, vocational Improved in normal settingsand rehabilitation services
Shelter, clothing, nutrition At risk, so responsibilities and coordinationand basic income should be clarified
Respite for families and carers Usually unchanged; place of treatment at home, offset by potential for increased professional support to family
Research and training New opportunities arise through decentralization
Source: Thornicroft G, Tansella M (2000). Balancing community-based and hospital-basedmental health care: the new agenda. Geneva: World Health Organization.
Strong commitment is required from all relevant stakeholders.
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Box 15. Examples of models of deinstitutionalization in practice
Brazil
Since 1991 there has been a 30% reduction in the number of psychiatric beds. From1997 to 2001 there was an increase from 176 to 295 in the number of community-basedmental health centres, called psychosocial care centres. Various projects have beencarried out in the South-Eastern Region, which has the country’s highest gross domesticproduct. In the State of São Paulo, the City of Santos, with a population of over 400000, had a highly profitable private psychiatric hospital with an authorized capacity of260 patients. In fact, it was housing 575 mental patients, many of them hospitalized foralcoholism. Numerous accusations of mistreatment and death through violence led theState Government to carry out an evaluation of the hospital in 1989, on the basis ofwhich the hospital was closed. Five mental health centres, called psychosocial attentioncentres, were established, similar to the model used in Trieste, Italy. With the participationof users’ associations and public functionaries this chain of centres evolved to the pointwhere workshops were set up to provide the patients with paid work. The psychiatrichospital was eventually closed. This experience is still one of the most important in theprocess of change in Brazil (Alves & Valentini, 2002).
Cuba
The development of mental health services in Cuba is a good example of the organizationof services with different models over the last 50 years.
- Asylum model (until 1959): Mental health services were scarce. There was only 1psychiatrist per 150 000 population. The services were centralized in Havana and weremainly in large mental hospitals (1 bed per 2200 population).
- Hospital model (1960 to 1986): Mental health services were integrated into thenational health system and resources were increased and decentralized to the wholecountry so as to improve access, coverage and quality. Psychiatric services in mentaland general hospitals were transformed into therapeutic communities. Attention waspaid to the development of human resources. The number of psychiatric beds increased.There were 11 mental hospitals, 15 psychiatric services in general hospitals and 4psychiatric services in paediatric hospitals.
- Ambulatory and primary care model (1987 to 1995): Some mental health serviceswere incorporated into primary care, 20 crisis intervention units were created and twopsychiatric outpatient clinics were developed in municipalities, outside the generalhospitals. Meanwhile, 30 day hospitals started to function and the number of psychiatricservices increased to 23 in general hospitals and 10 in paediatric hospitals. Thenumber of psychiatric beds increased to 1 per 1100 population. The policy of humanresources development, introduced in the previous period, led to a significant increasein the number of psychiatrists (1 per 9000 population).
- Community psychiatry model (from 1996): The ambulatory and primary care modelwere seen to be in need of improvement because they failed to modify psychiatricepidemiology, they showed a poor cost-benefit ratio, consumers were dissatisfied andthere was poor participation of the population. Through the participation of multiplestakeholders a new policy was formulated with the community mental health centres asthe core element of the services. These centres are staffed by multidisciplinary teams(including psychiatrists) and they use any infrastructure that is available at the local level(health facilities, schools, factories, community facilities, etc.). They are well connectedwith primary care centres (family doctors and nurses) and with various organizations
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belonging to sectors other than the health sector. By the end of 1999 it had beenpossible to accredit 111 community mental health centres. This strategy has allowedan understanding of the needs of the population in each locality, the development ofappropriate action plans and a reduction in the demand for inpatient treatment(Barrientos, 2001).
Key points: Recommendations for the organization of services
- Service planners should aim to have a range of mental health services.
- The absolute need for various services varies between countries but the relativeneeds for different services are similar in many countries.
- The integration of mental health services into primary care is a viable strategy forincreasing access to mental health care in many countries.
- Integration into primary health care requires the training of primary care staff in theidentification and treatment of mental disorders.
- In some countries, primary care staff are already overburdened and the integration ofmental health care into primary care, requires an increase in the absolute numbersof primary care staff.
- The integration of mental health services into general hospitals requires specialistmental health professionals in such hospitals and the provision of infrastructural andother facilities.
- The integration of mental health services into existing general health and socialcare programmes targeted at vulnerable populations represents a useful strategy forovercoming resource constraints and increasing the reach of mental health services.
- It is necessary to establish community-based mental health services in countries ifintegration and deinstitutionalization are to succeed.
- Countries should consider using existing networks of services, especially thoseprovided by nongovernmental organizations.
- Large mental hospitals are not justified by their costs, their effectiveness or thequality of care provided.
- Deinstitutionalization does not just involve discharging patients from long-stayhospitals. It is a process of reorienting the delivery of services mainly from a predominantlyinstitutional perspective to a community-based perspective.
- Deinstitutionalization should follow, not precede, the establishment of community-based alternative services.
- A small proportion of patients require long-stay facilities and they can be accommodatedin small units in the community or in small long-stay wards in hospitals.
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5. Key issues in the organization
of mental health services
The above recommendations for organizing mental health services have to take certainkey issues into account. These include the evidence base for mental health interventions,the unique needs of people with mental disorders, the way communities and patientsaccess services, and other important structural issues such as the need for intersectoralcollaboration.
5.1 Evidence-based care
The evidence base for some commonly recommended service provision strategies isreviewed below.
5.1.1 Community-based treatment and care without hospital admission
Eleven studies in developed countries have compared the effects of community-basedtreatment with those of standard inpatient care (Braun et al., 1981; Conway et al., 1994).The results are given in Table 1, where + indicates significantly better outcomes than incontrols and = indicates no difference between treatments and controls. Not all studiesmeasured the same variables. The last three studies involved multidisciplinary teams,24-hour access, crisis intervention, patient advocacy, continuing care and non-insti-tutional residential support or day centres as components of their community programmes.Table 1 shows that community-based treatment was associated with substantiallybetter outcomes than inpatient treatment and care.
Table 1. Studies comparing the effects of community-based treatment with thoseof standard inpatient care
Study Global Psychosocial Admission/ Length of Patient Less Employment Family
symptom- adjustment readmission stay in satisfaction medication burden
atology rates hospital
1 + +2 + + + + +3 + + + + +4 + + + + +5 + + + + +6 + + + + +7 + + +8 + + + = +9 + + + +
10 + + + +11 = = +
5.1.2 Hospital admissions followed by community based treatment
Thirteen controlled studies in developed countries have compared the use of shorterhospital stays or substituted day care with control patients who received long-termhospital care (Braun P et al 1981). Table 2 indicates that if admitted to hospital,shorter stays are as effective as longer stays.
There is clear evidence that, for many disorders, community-based treatmentgives substantially better outcomes than inpatient treatment..
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Table 2. Studies comparing the outcomes of short hospital stay or substituted daycare with those of long-term hospital care
Study Global Psychosocial Admission/ Length of stay Employment Family burden
symptomatology adjustment readmission rates in hospital
1 = + = +2 - + =3 = + = +4 +5 +6 + + = + +7 = = =8 = (one year) =9 = (two years) = =
10 = _11 = _12 + +13
5.1.3 Community-based treatment and care for persons with severe mental disorders
A selection of five valid studies comparing controls with community-based care forpersons with severe mental disorders who had previously been hospitalized for extendedperiods is presented in Table 3 (Braun et al., 1981), where + indicates a significantlybetter outcome than in controls and = indicates no difference from controls. Table 3 showsthat community-based treatment and care were associated with improved outcomes.
Table 3. Studies comparing controls with community-based care for those personswith severe mental disorders who had previously been hospitalized for extendedperiods
Study Global Social functioning Admission/ Independent living Employment Family burden
symptomatology readmission rates
1 =2 = + +3 + + + +4 + +5 + +
De-institutionalization is associated with good outcomes.
5.1.4 Treatment of major mental disorders
There is substantial evidence demonstrating that the major mental disorders can beeffectively treated and that relapse rates can be reduced by a combination ofpsychopharmacological and psychosocial rehabilitation interventions. In the treatmentof schizophrenia, for example, a combination of regular medication and familyinterventions can reduce the rate of relapse from nearly 50% to less than 10% (Leff &Gamble, 1995; Dixon & Lehman, 1995).
Programmes aimed at reducing depression in mothers and thus at reducing adverseoutcomes for their children have proved effective. They can be delivered in primary caresettings by, for example, health visitors and community health workers (Cooper &Murray, 1998). There is also evidence to show that depression can be effectively treatedby primary care personnel using a combination of medications and psychotherapy orcounselling (Mynors-Wallis et al., 1996; Schulberg et al., 1996; Ward et al., 2000; Boweret al., 2000; Sriram et al., 1990).
A full description of cost-effective interventions is available (World Health Organization,2001a).
5.2 Episodic care versus continuing care
Health systems in most countries, and especially those in developing countries, aredesigned to provide health care on the basis of the throughput model. This emphasizesthe importance of vigorous treatment of acute episodes in the expectation that mostpatients will make a reasonably complete recovery without a need for ongoing care untilthe next acute episode, if there is one. The model works well for a narrow range ofcommunicable diseases and is defended on the grounds that it helps to ration expertresources and discourages dependency. It is, however, ill-suited to the needs of manypeople with mental disorders whose conditions are only partially responsive to treatmentand whose medical condition is inexorably linked to difficulties in daily living.
Many mental disorders, especially those with a chronic course or with a relapsing-remittingpattern, are better managed by services that adopt a continuing care model. Thisemphasizes the long-term nature of the disorders and the need for a continuing therapeuticinput. A continuing care approach also emphasizes the need to address the totality ofpatients’ needs, including their social, occupational and psychological needs. Suchapproaches therefore require a significant degree of collaboration between differentcare agencies.
The sectorization or catchment area method of provision is an example of organizingservices so as to maintain continuity of care. The catchment area team takesresponsibility for the provision of care on an ongoing basis for persons living in adesignated geographical area.
Effective continuing care requires the coordination of patients’ medical and social careneeds in the community. In many developed countries this emphasis on coordinationhas led to the development of case management models of care. Case managementencompasses strategies aimed at minimizing service fragmentation by establishingcontact persons for the coordination of care (see Section 5.5).
5.3 Pathways to care
The pathways to care are the routes whereby people with mental disorders gainaccess to providers of mental health services. These pathways influence the organizationof services.
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Depression can be managed effectively in primary care.
The continuing care model helps to address the totality of needs of many persons with severe mental disorders.
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In established market economies the common pathways to care include:
- the primary care system;- referral from secondary and tertiary medical care facilities; - referral by other sources such as schools, social workers and courts.
In developing countries the most common pathways to care include:
- village health workers;- nurses; - primary care clinics; - traditional healers; - direct access to specialist services in the public or private sector.
These pathways may hinder access to mental health services because of:
- low awareness of available services;- a lack of well-organized primary mental health care;- inadequate links between services;- a lack of knowledge among rural populations about the causes of and treatments
for mental disorders, resulting in the underutilization of mental health services; - inadequate mental health training of general practitioners and traditional healers,
contributing to low rates of detection, treatment and referral of mental disorders in traditional and primary care settings;
- a failure of mental health services to actively identify cases in the community, users being required to find and access available pathways;
- difficulty in accessing specialist services, partly associated with the need for professional referral to specialist programmes.
These barriers often lead to negative outcomes, such as delays in seeking or obtainingcare until full-blown disorders have developed with a higher likelihood of poor long-termoutcomes and greater costs of treatment.
Service planners should organize services so as to overcome these barriers, improveaccess and thus reduce the duration and severity of disability caused by mental disorders.Some countries have attempted to overcome these barriers by improving communicationwith local communities in order to increase the visibility of formal mental health services.Communities need information about the availability of mental health services. Suchinformation should be disseminated through both formal and informal means.Community health workers and primary care workers can actively promote mentalhealth issues and undertake early identification work in communities. The creation ofclear referral mechanisms from primary care to secondary mental health services andvice versa is another strategy for reducing barriers to care (see Section 9).
5.4 Geographical disparities
In all developing countries there is an imbalance of resources between mental healthservices in rural settings and those in urban settings. Innovative rural programmes aretherefore necessary in countries lacking many of the basic mental health resources, e.g.primary care centres and psychiatric units. Health care personnel in many countries arereluctant to serve in remote rural areas because of a lack of general facilities. It may benecessary to consider providing financial or other professional incentives in order toinduce staff to serve in remote areas. In countries with reasonable transport links anoutreach service from primary or secondary mental health services to rural and remoteareas may represent a feasible option for extending services. Yet another strategyinvolves training village-level workers in the basic identification of mental disorders and
Established pathways to care and treatment may hinder access to services and lead to poor outcomes.
It is necessary to address geographical disparities.
providing them with weekly or monthly supervision by visiting mental health professionals(see Section 10, Barrier 2 and solutions).
5.5 Service-led care versus needs-led care
In order to be effective, mental health services have to focus on the needs of patientswith mental disorders and provide services to meet these needs. However, mentalhealth services often encounter problems in the implementation of this well-understoodand well-accepted principle of care.
Many services, including those of health care, social work, social security and housing,are arranged hierarchically with distinctions between service levels and serviceproviders. These distinctions include separate managerial arrangements, separatebudgets and differences in the modes of entry into services, e.g. referral systems. Theseservices have often developed independently from each other. For example, health carebudgets are held and implemented by health ministries while housing budgets arecontrolled and disbursed by housing ministries. In most cases these organizationalarrangements are based primarily on a managerial perspective and users have to adjustto the peculiar structures of the services they need to access.
These organizational arrangements cause considerable difficulties for people withmental disorders. In theory, users should be able to move seamlessly, in accordancewith their needs, between different service levels and service providers. But for peoplewith mental disorders these organizational structures often become barriers to obtainingthe care they need.
In order to address this problem it is essential that services be designed on a needs-ledbasis rather than on a service-led basis. This means adapting services to users’ needs,and not the other way round.
The coordination of care is an important aspect of developing needs-led care. In manyinstances it is necessary for mental health services to link with and coordinate the activitiesof agencies outside the health sector, e.g. housing, employment and social security, inorder to obtain the services required by patients.
The implementation of a needs-led service structure does not always require additionalfinancial resources. It does, however, require a commitment to adapt services topatients’ needs. If, for example, patients have to travel long distances to clinics, theirneeds can be met if the clinics are opened in the afternoon rather than in the morning.This has no financial implications for the services.
The key points are that the needs of populations should be reviewed locally, considerationshould be given to how services are accessed locally, and service provision should bemodified so as to maximize the probability of meeting patients’ needs.
There are moves towards needs-led models of service provision in many industrializedcountries and in some developing countries. Examples include brokerage models andassertive case management for patients with severe mental disorders (Stein and Test,1980) and a model for psychosocial rehabilitation adopted in rural settings in Tanzania(Box 9). These models are an acknowledgment that patients’ needs should be consideredfirst and foremost and that the organization of services should be adapted in order tomeet them.
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Service organization sometimes does not take into account the needs of people with mental disorders.
A needs-led model of service provision can beeffectively implemented.
The key point is that servicesshould review the needs of localpopulations in order to maxi-mize the probability of meetingthe needs of people with mentaldisorders.
5.6 Collaboration within and between sectors
People with mental disorders have complex needs that cut across service sectors. It isunlikely that the health sector alone can meet all the needs of these people for socialcare. In developing countries, moreover, the mental health sector may be relatively smallin comparison with the other sectors that may be able to supplement its activities.Collaboration is therefore essential if the outcomes of mental disorders are to be improved.
Collaboration is needed within the health sector, i.e. intrasectoral collaboration, andoutside the health sector, i.e. intersectoral collaboration.
Collaboration within the health sector involves links with primary and secondary mentalhealth care, links between the mental health sector and the general health sector at theprimary, secondary and tertiary levels, links with traditional systems of medicine, linkswith nongovernmental organizations in the health sector, links with national andmultilateral donor agencies in the health sector, and links with international agenciessuch as WHO.
Collaboration outside the health sector involves working with government departmentsand nongovernmental agencies concerned with housing, employment, social welfare,education and criminal justice among others.
5.6.1 Examples of levels of collaboration
Intersectoral collaboration can take place between the above agencies at various levels.
a) At the most basic level, collaboration can involve mutual data-sharing and informationexchange, thus increasing awareness between collaborators. b) At a higher level, agencies are involved in consultation and planning but specificservices are still delivered by a particular agency.c) More intense collaboration involves agencies working together in the planning anddelivery of new services.d) At the most intense level there are joint funding arrangements and joint managerialresponsibilities for specific services that are developed jointly by the collaboratingagencies.
5.6.2 Enhancing collaboration
The requirements for effective collaboration include, first and foremost, an acceptanceby the agencies concerned of the need for collaborative efforts. Mental health agenciesand the people involved in the planning and delivery of mental health services have totake a lead in explaining and convincing people in other sectors, especially thoseoutside health, of this need. Some ways of enhancing collaboration include: involvingother sectors in policy formulation; delegating responsibility for certain activities toagencies from other sectors; setting up information networks that involve agencies fromother sectors; and establishing national advisory committees with representatives ofrelevant agencies from sectors outside mental health (Box 16).
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Collaboration within and between sectors is essential for meeting the complex needs of persons with mental disorders.
Collaboration can take place at various levels.
Agencies can benefit substantially from collaboration.
Box 16. Strategies for enhancing collaboration
The basic areas of collaboration include the exchange of information on: philosophy,policy and the range of ongoing activities; areas of success; existing problems; andareas of need. Personal visits are very effective in building networks and bridges.These should be complemented by meetings, brainstorming workshops, newsletters,telephone conversations, correspondence and the use of web sites where possible.
Policy formulationPolicy formulation should involve as many relevant sectors as possible. Governmentmay decide to delegate the task of collecting ideas and seeking consensus to anagency, e.g. a university institution, with appropriate experience. This might involve, forexample, holding a planning meeting with all stakeholders in order to clarify the mentalhealth policy interests of the participants.
Delegation of responsibilitySome government agencies, e.g. regional consultant hospitals, could take up theresponsibilities of training and supervising mental health workers in their regions.Professional organizations might take up the function and responsibility of producingeducational or training materials for mental health workers. Governments might providesubsidies to voluntary bodies for the purpose of providing mental health services tocommunities. It is also conventional for governments to establish contracts withinstitutions or individuals in universities for the monitoring and evaluation of activities inthe field of mental health. In many instances this approach is more cost-effective thansetting up research organizations in health ministries.
Information and the coordination of mental health programmesIt is important to keep lines of communication open in order to maintain organic coherencebetween the various sectors involved in mental health promotion. The motivation of allactors and stakeholders requires them to be informed about what is happening all thetime. Communication can be maintained through electronic media, briefs and newsletters.
Setting up information and communication strategies or networksThe process of setting up networks, information systems and communication strategiesis most likely to follow the policy development process. Stakeholders may have to beinvolved from the outset, defining what they need to communicate about and howcommunication can be achieved. The outcome, therefore, is likely to be dictated by theobjective situation obtaining in the country concerned.
Establishment of national advisory and coordinating committeesIt is important that national planning committees, representing all stakeholders, shoulddefine the various advisory committees and their functions as well as their membership.These committees should preferably include representatives of all the stakeholders.Umbrella organizations may represent a number of bodies on these committees in orderto keep them small and functional.
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Key points: Issues concerning the organization of mental health services
- There is evidence from developed countries that community-based treatments aremore effective or at least as effective as hospital-based treatments.
- There is evidence that depression can be successfully treated in primary care settings.
- Mental disorders that run a chronic course or a relapsing remitting course are bettermanaged by services that adopt a continuing care approach, emphasizing the long-termnature of these disorders and the need for ongoing therapeutic input.
- The pathways to care differ in developing and developed countries. Existing pathwaysmay hinder access to care in some instances and may have to be reformed.
- It is necessary to address geographical disparities in the provision of mentalhealth services.
- Mental health services should adopt a needs-led approach.
- The complex needs of persons with mental disorders cut across sectors and cannotbe met by the mental health sector alone. Collaboration within the health sector andwith other sectors outside the health sector is therefore necessary.
- The first step towards effective collaboration is acknowledgement of the need for it.
- Some ways of enhancing collaboration include: involving other sectors in policyformulation; delegating responsibility for certain activities to agencies from other sectors;setting up information networks involving agencies from other sectors; and establishingnational advisory committees representing relevant agencies from sectors outside themental health sector.
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6. Recommendations and conclusions
A number of general recommendations of how services for mental health can beorganized to optimise the delivery of high quality care are suggested below. These needto be considered and adapted according to the specific country context.
- If possible, large and centralized psychiatric institutions should be closed down andmore appropriate community-based alternatives should be provided. It may not be realisticto take this course immediately in many countries. In the short term these institutionsshould be reduced in size, the living conditions of the patients should be improved, andstaff should be trained to deliver care in the community and improve the quality of care.These institutions should be converted into centres for active treatment and rehabilitation.
- As far as possible, all new admissions to mental hospitals should be stopped.Patients needing admission to hospital should be accommodated in psychiatric units ingeneral hospitals.
- Existing financial and human resources should be diverted from large mentalhospitals to mental health care services in primary care and to community-based mentalhealth services.
- The integration of mental health services into primary care and general hospitalsshould be given priority. Integration forms the basis for reorienting services from theinstitutional perspective to the community-based perspective.
- In developing countries, specialized mental health services should be made availablein general hospital settings at the district level.
- Informal mental health care, provided by families, self-help groups or volunteerworkers, should be maximized by improving the general understanding of mentaldisorders and their causes, the available treatments, and management skills. Supportand education groups for families and other carers should be maximized.
- Financial disincentives should be used in order to discourage care in specializedpsychiatric institutions, and financial incentives should be used to promote care in generalhospitals and the community.
- In developing countries, mental health specialists should be used wisely in thetraining and supervision of less specialized mental health workers.
- The service provision gap between rural and urban areas, and underprovision in anyunderserved populations, should be reduced by extending the reach of general healthservices and community mental health services.
- The training of health care professionals should encompass the psychosocial aspectsof care along with skills and knowledge about appropriate medical treatments.
- Consideration should be given to both the short-term and long-term requirementsfor the training of specialist and general health workers. In developing countries it isjustifiable to emphasize the training of general health workers in the short term and in thelong term. Attention should also be paid to increasing specialist capacity in the long term.
- The involvement of consumer and family organizations in service planning anddelivery should be encouraged and increased.
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7. Scenarios for the organization of services
in countries with various levels of resources
These scenarios use two fictitious countries similar to those described in Mental HealthPolicy, Plans and Programmes.
Country A with a population of 10 million and a low level of resources
- There are two mental hospitals in the country which limit admission to persons with severe psychosis and disruptive behaviour.
- Outpatient treatment is available only in four cities and covers 40% of the population.
- The country has 20 psychiatrists, 30 psychologists and 80 psychiatric nurses. About 30-50% of their time is spent on private practice and teaching.
- There is a good network of primary care centres and a basic level of primary care is available in nearly all rural and urban areas.
The main aims in organizing services should be to improve access to outpatient andinpatient services throughout the country, especially for people living in rural areas, andto help persons with mental disorders to continue living in the community.
The following steps should be taken.
a) Prioritization should be undertaken in respect of certain mental health conditions. Itis important that the community be consulted when priorities are decided so that itsperceived needs are addressed. This can be achieved by consulting widely with mentalhealth professionals, community leaders, and people with mental disorders and theirfamilies. Two possible outcomes follow from such consultation. The community and theprofessionals may either identify common mental disorders, i.e. depression and anxiety,that should be prioritized for action because they affect the lives of many people andbecause the cumulative disability for the population is much greater than that causedby severe mental disorders, or they may decide that severe mental disorders with achronic course should be prioritized for action because they cause significant disability inthe persons concerned, hardship for the families of these persons and disruption to thesocial life of other community members. b) The next step should be to ensure that the limited number of mental health profession-als is used to obtain maximum benefit. As far as possible, mental health professionalsshould be used for training, supervision and dealing with referred cases rather than fordirect service provision for all persons with mental disorders. c) Direct services should be provided by primary care workers, who should be trainedand supervised by the mental health professionals. The primary care workers shouldrefer specific cases to mental health professionals, who should provide specialistconsultations, draw up treatment plans and send patients back to the primary careworkers for the implementation of these plans.d) Admission beds should be made available in as many general hospitals as possible.Each general hospital should therefore have at least one psychiatrist, one psychologist andfour psychiatric nurses in its admissions unit. The mental health professionals should alsoprovide a consultation and liaison service to patients admitted for physical disorders. e) Long-stay patients in the two mental hospitals should be reviewed in order to assesstheir long-term needs for treatment and care. Assessments should attempt to ascertainthe level of support required in order enable the patients to live in the community. As afirst step, all new admissions to these two hospitals should be stopped and the patients in question should be directed to the general hospital nearest to their home for admission.
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A clear plan should be drawn up for discharging patients from these hospitals over aperiod of five years. This process should start with those patients with the least disabilityand with families who are willing to take them home. Ongoing treatment of the patients’mental disorders should be handed over to local primary care centres and provisionshould be made for periodic reviews of their treatment by mental health professionalsat the general hospitals nearest to their places of residence. f) Training should be started for staff working in other health programmes, e.g. in theHIV/AIDS programme, and for health care staff involved in providing reproductive andchild health services.
Country B with a population of 10 million and a medium level of resources
- Some primary care centres deliver basic treatment for mental disorders and one nongovernmental organization has a programme on life skills and the school health environment.
- Most mental health resources are concentrated in two cities: there are two inpatient units in general hospitals and there is a large mental hospital.
- There are 100 psychiatrists, 40 psychologists, 250 psychiatric nurses and 40 occupational therapists.
The main aim in the organization of services is to extend access to them to underservedpopulations, especially in rural areas.
This country should take the following steps.
a) The mental health conditions that are to be addressed should be prioritized (seecountry A above).b) All primary care centres, especially those in rural areas, should deliver basic treatmentfor mental disorders. This requires all the staff in primary care centres to receive training inmental health and continuing weekly supervision by mental health professionals. c) Some mental health professionals should devote a significant part of their workingtime to dealing with specialist referrals from primary care staff. d) Outpatient clinics should be started in all primary care centres. These clinics shouldinitially function as specialist clinics and should be held once a week. Psychotropicmedications should be made available in all primary centres. e) Referral links should be set up between primary care centres and psychiatric unitsin general hospitals. This process may be aided by dividing the country into sectors andidentifying the catchment area for each psychiatric unit. Primary care centres in thecatchment area of a general hospital’s psychiatric unit, should refer patients to, andreceive supervision from, the mental health professionals in that unit.f) Inpatient psychiatric beds should be set up in all general hospitals. General hospitalsin rural areas or other areas where access is poor should be prioritized for funding andhuman resources. g) There should be collaboration with the nongovernmental organization in order toprovide services for children and adolescents. Members of staff of the nongovernmentalorganization should be trained to identify mental disorders and to acquire basiccounselling skills. h) A plan should be implemented for gradually reducing the number of beds in thelarge psychiatric hospital (see country A above).
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Barrier 1
Primary care staff receiving skills training in the field ofmental health may not necessarily apply their newlyacquired knowledge in the course of their duties. InGuinea-Bissau, for example, primary care workers did notapply their skills to the identification and treatment of majormental disorders on their own initiative (De Jong, 1996).
Solutions
1.Regular supervision and consultation with a designat-ed team of mental health professionals was effectivefor primary care nurses in Guinea-Bissau.
2.Resistance to providing psychosocial counsellingmay be attributable to a cultural reluctance to discussemotional issues frankly, a continued belief in thesomatic basis of many minor mental ailments, or theattribution of the symptoms to a traditional supernaturalfactor on the part of both primary care workers andpatients. The primary care nurses in this example mayhave required additional training to address theneed for psychosocial counselling. The example ofZimbabwe (Abas et al., 1995; Patel, 2000) suggeststhat community-oriented research using key informantscould help to identify common local idiomatic forms ofminor mental ailments and generate recommendationsfor treatment. These should form the basis of aculturally relevant diagnosis and treatment programmeoffered by primary care nurses. The educationalcomponent should consist of learning to identify andtreat these idiomatic forms of minor mental disorderson the basis of using the information gathered fromboth nurses and the community.
3.Cambodia represents the inverse of the problemfound in Guinea-Bissau, viz. the resistance of somelocal mental health trainers to incorporating traditionalconcepts into the mental health training package(Somasundaram et al., 1999). The solution is similar tothat in the example from Guinea-Bissau in that itrequires demonstrating to local health workers howlocal idiomatic forms of mental illness complement orcoincide with Western categories of mental disorder.Cross-cultural issues should therefore form an explicitcomponent of the skills training package.
8. Barriers and solutions
Some of the barriers hindering the organization of mental health services are discussedbelow and ways of overcoming them are suggested. The solutions indicated are notnecessarily the only ones that might be applied in order to achieve effective andappropriate mental health services.
Barrier 1
Problems of motivating primary care staff to apply their training in the field of mental health.
Solutions
Regular supervision.
Use local idiomatic forms of mental illness as the basis of training.
Demonstrate the correspondence between local and Western categoriesof mental illness.
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Barrier 2
Geographically large countries that are poor and havepredominantly rural populations may find it difficult toestablish workable networks of mental health servicesat the level of primary care because of a lack of financialand human resources in outlying primary care clinics.
Solutions
The example of Botswana illustrates that psychiatricnurses who regularly visit remote rural primary careclinics represent a cost-effective way of spreadingscarce mental health personnel over vast geographicalregions (Ben-Tovim, 1987). The use of psychiatricnurses would be even more effective if village-levelmental health workers aided them in identifyingvulnerable cases in the community. Such mental healthworkers should identify patients and refer them tolocal primary care clinics on the days when psychiatricnurses make their visits. Another possibility would beto train volunteer village community mental healthworkers on the basis of the core-group trainer concept(Somasundaram et al., 1999).
Barrier 3
For many countries the provision of adequate cost-effective mental health services can be maximizedthrough an increasing emphasis on intersectoralcooperation. However, this is by no means astraightforward process.
Solutions
1.The examples of Tanzania (Kilonzo & Simmons,1998), Zimbabwe (Abas et al., 1995), Cambodia(Somasundaram et al., 1999) and India (Box 6) illustratethat cooperative approaches can occur at the nationalor local level and can bring together local communitymembers, service providers and social agencies.Cooperation between mental health services, generalhealth services, traditional healers and communitymembers is very important, leading to the developmentof cost-effective and appropriate primary-level mentalhealth services.
2.Services such as psychiatric agricultural rehabilitationvillages and counselling for depression in primary careare structured on the basis of a network of cooperationbetween mental health services and various othersectors. These services are products of intersectoralcooperation, and in developing countries it may behelpful to think of the mental health system as acollaborator with other sectors in providing personnel
Barrier 2
Geographically large countriesmay have difficulty in implementing coordinatedmental health services at the primary care level.
Solutions
Regular visits of psychiatricnurses to designated primary care clinics.
Training for village-level community health workers.
Barrier 3
A lack of intersectoral cooperation impedes thedevelopment of innovative and cost-effective mentalhealth services.
Solutions
Programmes that forge links between mental health services, general health services, traditional healersand local communities.
Coordinate a collaboration network in order to providemental health services.
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(psychiatrists, psychiatric nurses, primary care nurses,medical attendants, traditional healers, teachers, villagehealth workers, etc.), services (psychiatry, primarycare, traditional healing, education), and service items(pharmacotherapy, counselling, herbal cures, relaxationand meditation exercises).
Barrier 4
Existing services often obstruct the early detectionand treatment of mental disorders. The late entry ofusers into the specialist mental health system is oftenattributable to previous ineffective contacts withtraditional or primary care providers. This occurs forthe following reasons.
1.There may be a lack of knowledge among ruralpopulations concerning the causes of and treatmentsfor mental disorders.
2.A lack of mental health training and of coordinationof activities between traditional healers, primary carestaff and mental health professionals may contributeto the absence of early detection and treatment at theprimary care level.
3.Primary care personnel may remain in clinics oroffices instead of actively visiting communities in orderto promote mental health and identify persons withmental disorders who are in need of treatment.
Solutions
1.Apart from specialized training for primary carestaff, countries with a more active communityapproach to care, e.g. the Czech Republic and India,have established better communication with localcommunities and have thus made the pathways tomental health services more readily visible. Wherecommunity health workers and primary care workersactively promote health education and early identi-fication in communities, vulnerable persons and theirfamilies are more likely than would otherwise be thecase to know about and use mental health services asopposed to traditional healers.
2.Lines of communication can be improved if:
(a) home visits are made by community health workers and general practitioners;(b) regular meetings are held with community members such as teachers, religious leaders and traditional healers; (c) there is community screening for major mental disorders on the basis of an assessment scale
Barrier 4
Failure of services to detectpeople with mental disordersbecause of fragmented care, ignorance and poor communication on mental health.
Solutions
Active health education and early identification in communities at the primarycare level lead to improvedoutcomes and a reduction in the cost of care.
such as that of the general health questionnaire (Breakey, 1996c).
3.A reciprocal network of communication for primarycare staff and specialist mental health services atthe secondary and tertiary levels is required forcomplex cases of severe mental disorders orcomorbid disorders.
Barrier 5
In many countries, mental health funding, personneland services are concentrated in tertiary-levelinstitutions. In contrast, a community-oriented approachemphasizes:
(1) dedicated services for population groups; (2) multidisciplinary personnel; (3) treatment close to people’s homes, with minimaldisruption of family and social networks, in preference to chronic institutional settings.
However, medically trained mental health staff andthe administrative bureaucracies responsible for theorganization of mental health services often resist thisdecentralized community approach to service provision(Gallegos & Montero, 1999; Rezaki et al., 1995; Tomov,1999).
Solutions
1.Staff resistance to a shift in resources to secondary-level and primary-level settings in the community canbe overcome by restructuring the teaching curriculumso that it includes community and public healthapproaches to the management of mental health issues.
2.A concerted effort at national level to involve existingtertiary-level staff in structural change is required. Ifthe roles of personnel are not diminished but redefinedwith their cooperation, resistance to a shift in resourceallocation is likely to be less than would otherwise bethe case. For example, psychiatrists, psychologistsand psychiatric nurses can take on a variety of rolesranging from direct clinical care to planning andconsultation.
3.The example of the former Eastern Bloc countriesindicates that both mental health staff and centralizedadministrations often resist a shift in service prioritieseven though gaps in service provision are recognizedby users and newly elected governments (Tomov,1999). In this context, governments may wish to side-step centralized bureaucracies by switching funds tonongovernmental organizations or other non-profit
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A reciprocal consultation network involving all three levels of service provision.
Barrier 5
The concentration of financial and human resources in tertiary mental health institutions.
Resistance to changing to community care among mental health and administrative staff.
Solutions
Restructure the teaching curriculum so that it embracesa public health approach to mental health.
The roles of tertiary-level staff can be redefined in relation to clinical, planningand consultative functions.
Shift funds from tertiaryproviders to nongovernmentalorganizations, primary care or community-orientated mental health services.
service providers that offer decentralized community-oriented mental health services at the secondary andprimary care levels. In the Czech Republic, for example,FOKUS, a nongovernmental organization providingvarious mental health services, receives funding fromseveral government ministries (Holmes & Koznar,1998).
4.Intersectoral collaboration between governmentministries, private non-profit service providers andnongovernmental organization providers can beexpected to become increasingly important in shiftingresources from tertiary to secondary and primarymental health services in communities.
Barrier 6
Some developing countries possess more communityresidential and outpatient mental health services thanothers. Nevertheless, few developing countries havea sufficiency of these services in their rural regions,and community services may be inadequate for children,adolescents and the elderly in urban or rural regions.
Solutions
1.Human and financial resources should be shiftedfrom institutional settings at the tertiary and secondarylevels to community settings at the secondary andprimary levels of service provision. The examples ofcountries that have managed this change (e.g. India,Israel) indicate that it can occur through national orregional initiatives involving:
- resource allocation; - staff training; - follow-up of trained staff; - intersectoral cooperation with families of users,
community members, other categories of health workers, and education and social services.
2.Without strong government interest in the provisionof community alternatives to institutional mentalhealth services, little progress can be made beyonda private niche market in urban settings. This isparticularly true in relation to mental health servicesfor children, adolescents and elderly people whorequire special provision in the areas of policy legislation,staff training and budget allocations.
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Intersectoral cooperation isvital in order to shift resourcesfrom the tertiary level to otherlevels of mental health care.
Barrier 6
Scarce community mental health services.
Solutions
National and regional planning initiatives for resourceallocation, staff training, performance evaluation andintersectoral cooperation.
The developmentof community mental health services requires the cooperation of serviceproviders and health department personnel.
Community mental health services for children, adolescents and elderly peoplerequire government commitment and special provision at the national or regional level.
Barrier 7
Some countries have attempted to shift the provisionof mental health services to the primary level of care,i.e. with programmes aimed at integrating mentalhealth services into a pre-existing primary care networkcatering for physical health. These attempts haveencountered many barriers.
- General practitioners, nurses and communityhealth workers located in primary care centres usuallylack training in mental health despite being the firstline of consultation for patients with mental problems.The same is true of general practitioners in privatepractice.- Without sustained skills training and active follow-upof primary care staff, the integration of a mental healthcomponent into the detection and management ofmental health problems is unlikely to occur. - Consultations last only about five minutes in manydeveloping and developed countries. Consequently,much of the mental health skills training received byprimary care workers is wasted, as little in the way ofknowledge or services can be operationalized in sucha short time. - General practitioners do not always have long-term continuity with individual patients and may notcommunicate with family members or traditional healersabout mental health problems in the community.
Solutions
1.The solution to the first two points lies in changingthe emphasis of training for primary care workers andin constructing a sound consultation and referralnetwork that enables easy access to mental healthprofessionals at the secondary and tertiary levels ofcare. The training of established primary care teamsshould preferably occur in the settings where they seepatients, and should involve simple steps in thediagnosis and management of both common andsevere mental disorders.
2.The training of new primary care staff in the field ofmental health requires a change in emphasis from aninstitutional psychiatry model to a community-basedpublic health model (Ozturk, 2000).
3.One possible solution is to link mental health needswith general health concerns that have a highernational priority but are nevertheless very relevant tomental health, e.g. AIDS. This enables funding tobecome available for the training of primary care staffin a variety of mental health skills. For example, theneed for counselling skills within the framework of anAIDS prevention programme has resulted in the
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Barrier 7
Problems in providing mental health services in primary care settings.
Solutions
The training of established primary care teams shouldoccur in service settings and should involveprogrammes in diagnosis,management, and follow-upconsultations.
The mental health sectorshould link its own initiativeswith general health priorities in order to obtain funding for primary mental health care services.
appropriate skills training of primary care personnel inSouth Africa (Freeman, 2000). In the context of primarycare the mental health sector should work in closecooperation with the general health sector at thenational level in order to take advantage of such trainingopportunities. Other linkages between specialistmental health and general health concerns couldinclude the integration of:
- a children’s mental health component into mother and child health care;
- an adolescent mental health component into AIDS and substance abuse programmes;
- child and adolescent mental health concerns into health education in schools;
- a geriatric mental health component into programmes for family health and home visits.
4.The problems of brief consultation periods in primarycare in some countries could be solved by a moreactive approach to early identification in the community.This would save the time of general practitioners inmaking diagnoses and would enable them to set upmanagement programmes whereby follow-up wouldbe performed by health workers. In India, whereprimary care workers already visit local communitiesin connection with general health issues(Channabasavanna et al., 1995), mental healthpromotion and early identification could be integratedinto these activities. This would make the diagnosticand management tasks of general practitionersmore feasible in the limited time available forconsultation.
5.If the national model of primary care involvesimpersonal clinical care by general practitioners and nocontinuity of personal contacts between patients anddoctors (Üstün & Von Korff, 1995), community healthworkers or nurses from clinics should conduct periodicfollow-up visits with patients in their community settings.
Barrier 8
Many countries have fewer mental health resources inrural settings than in urban settings. This is especiallythe case for all tertiary services and specialist child,adolescent and geriatric services. In addition, theneed to shift financial and human resources from tertiaryto secondary and primary care in community settings(see barrier 5 above) there is also a need to shift suchresources from urban settings to rural areas. Thesolution to the first issue may result in urban areasdeveloping an array of secondary and primarycommunity mental health services while remote ruralregions remain without comparable resources and
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Active mental health promotion and early identification by primary or local community mental health workers.
Barrier 8
The urban bias: there are fewerhuman and infrastructuralresources for mental healthservices in rural areas.
services. Shifting funds to rural areas may not resultin significant numbers of mental health professionalsmoving to these regions, which is a major problem formental health services that rely heavily on humanresources. A significant shift of mental health infra-structure from urban to rural areas is unlikely to occurin most developing countries because of the financialconstraints on national health budgets.
Solutions
1.The training of local community workers who canassume some of the responsibility for the earlyidentification of vulnerable community members andparticipate in the long-term management of suchpatients after consultation with primary care generalpractitioners or nurses. Skill components may includeattention to the developmentally different mentalhealth needs of children, adolescents and the elderly.
2.Mental health skills training for rural schoolteachersin order to provide health promotion and early identi-fication of mental health issues for children andadolescents.
3.Mental health skills training for local village andreligious leaders including components relating tochildren, adolescents and the elderly.
4.Mental health skills training for primary health careworkers and their ongoing consultation and follow-upby mental health specialists were discussed above(see Barrier 7).
Barrier 9
Despite the relative scarcity of mental health servicesin many countries, particularly in rural regions, therehave been few sustained attempts to integrate amental health component into primary care.Furthermore, community residential and outpatientservices are poor in rural areas in both developedand developing countries. A major obstacle to planningfor primary mental health care and communityservices is a lack of initiative at the national level forachieving cooperation between mental health care,primary care, and other sectors involved in mentalhealth, e.g. those of education, social services,correctional services, nongovernmental organizationsand donor agencies.
- If cooperation between these sectors is absent atthe national level it is comparatively difficult for it tooccur at the tertiary, secondary and primary levels ofservice provision.
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Solutions
Train rural community healthworkers in early identificationand attention to the developmental needs of children, adolescents and the elderly.
Train rural schoolteachers in mental health promotion and the early identification of children and adolescents.
Train rural village and religiousleaders in health promotionand care of the elderly.
Barrier 9
National insensitivity to the need for intersectoralapproaches
- The effectiveness and accessibility of availablemental health services may be compromised by a lackof intersectoral cooperation at the point of serviceprovision.
- Different government ministries may run similarpsychosocial programmes without coordinating orstreamlining their resources.
- There may be a lack of coordination between serviceproviders and social agencies working with targetpopulations, e.g. the police, correctional services,social welfare, education and organized religion.
- A lack of coordination between mental healthservices and important informal sector participantsmay occur, e.g. families of people with mental disordersand traditional healers. This deficiency reduces thevisibility and accessibility of services to the targetgroup of potential users.
Solutions
1.The examples of India (Box 6) and Israel (Box 9)suggest that regional or national governments shouldinitiate intersectoral approaches to filling gaps inmental health services at all levels of care.
2.Intersectoral approaches should begin withcooperation at the national or regional level betweengovernment departments and the providers of mentalhealth services, including public, nongovernmentalorganization and private for-profit providers.
3.An intersectoral approach can be replicated at thedifferent levels of care by emphasizing the importanceof the consultation network.
4.At the tertiary level this network includes mentalhealth specialists forging links with related specialistfields in their own institutions. It also includes theforging of links with regional representatives of thepolice, education and social welfare sectors, non-governmental organizations and insurers in connectionwith the planning and implementation of specialistservices, e.g. for children, adolescents and elderlypeople.
5.At the secondary level the network includes mentalhealth workers consulting other sectors, includinglocal municipal representatives of the police, education,organized religion, other social services and non-governmental organizations. The consultations shouldcover the coordination, planning and implementationof community mental health facilities and rehabilitationservices. In addition it is desirable to consult regularly
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Solutions
Regional or national governments should initiateintersectoral action to fill gapsin mental health services.
Cooperation between government departments and all mental health service providers.
Cooperation between tertiaryproviders, regional governmentdepartments, nongovernmentalorganizations and insurers in planning specialist services.
Cooperation between secondary providers, localgovernment departments, nongovernmental organizationsand community and religiousleaders in planning communitymental health services.
with the families of people who have mental disordersand with traditional healers.
6.At the primary level the network includes consultationswith local community health workers and individualcontacts with local police, teachers, clerics, non-governmental organizations, family members andtraditional healers. These consultations should coverthe coordination, planning and implementation ofprimary mental health education, the prevention ofmental disorders and the promotion of programmes incommunity settings.
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Cooperation between primaryproviders, local institutions,nongovernmental organizationsand individuals from communities in the implementation of programmesfor the promotion of mentalhealth and the prevention of mental disorders.
9. Glossary
Closed institutions / Institutions whose working is not open to scrutiny and inspectionby outside agencies, and which do not encourage such scrutiny. The term does notrefer to institutions that have closed down and are non-functional.
Double funding or hump funding / The provision of financial resources for operatingan existing service and a new service during a transitional period when there may be anoverlap in respect of the services provided and the group or groups served. The ultimateaim is to terminate the existing service once the new service is fully operational and ableto meet the needs of the identified target group or groups.
Indirect costs / Costs, apart from direct service costs, incurred by people with mentaldisorders and their families. For example, people with mental disorders may have to payfor transport so that they can travel long distances to services, or they may lose incomeas a result of having to spend time away from work while they attend clinics. Familiesmay lose income if family members have to stay at home and care for persons withmental disorders.
Revolving door syndrome / A cycle of admission to hospital, discharge and readmission.This may happen, for instance, because of non-adherence to medications or a lack offollow-up by community-based services, with the result that patients with mentaldisorders experience relapses.
Stand-alone services / Mental health services that generally function in isolationand do not have strong links with the rest of the health care system. They have littleinterdependence or reliance on other parts of the health system for meeting the needsof their patients.
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